Background
Common mental disorders (CMDs) is a leading cause of disability both internationally and in Sweden [
1,
2]. Sick leaves due to CMDs are often longer than sick leaves in general and women are over-represented in this group [
3,
4]. Long-term sick leave is associated with negative economic and health consequences [
5]. It is, therefore, urgent to identify factors that facilitate return to work (RTW) in this group. Among individuals with CMDs, earlier RTW may be achieved by reducing the symptom burden from the CMD or increasing perceived health [
6]. Support from the workplace is important as well [
6]. However, to meet the growing challenges associated with increasing rates of long-term sick leave for CMDs, there is a need for investigation of RTW intention [
7], i.e. its determinants as well as its importance for RTW. Subsequently, the present study is a first step in investigating RTW intention among women on long-term sick leave due to CMDs, by focusing on identification of determinants of RTW intention. The Theory of Planned Behaviour is well-suited to investigating intention and its determinants [
8]. By investigating the relationship between RTW beliefs, psychological well-being, perceived health and RTW intentions, comprehensive knowledge about what constitutes RTW intention among women on long-term sick leave due to CMDs can be generated.
Long-term sick leave, i.e. sick leave > 2 months [
9], due to CMDs has increased in Sweden during the past decade, primarily among women [
3]. Long-term sick leave may entail negative consequences for health-related aspects of life such as sleep, leisure activities, lifestyle, habits (food, exercise, reading etc.) and psychological well-being [
5]. Several diagnosis groups within the overarching category of CMDs (i.e. stress-related disorders, depression and anxiety disorders), result in sick leaves of longer duration than sick leaves in general. Exhaustion syndrome accounts for the longest sick leaves, approximately 6 months [
2] or longer [
10]. Women are especially vulnerable to stress-related disorders such as exhaustion syndrome [
2]. One proposed explanation for women’s higher prevalence of CMDs is their role as head of household [
11], especially after the first child is born [
12]. Women have also been shown to more often experience a family-work conflict, i.e. difficulties balancing demands from home and demands from work [
13]. There is also a suggestion that women are assessed differently by health care personnel and are therefore put on sick leave more easily [
12]. All of these mentioned causes for CMDs may negatively affect women’s beliefs about RTW and research has shown that female gender is associated with delayed RTW among individuals with mental health disorders [
14]. However, RTW is not only about work resumption, but also to stay at work [
15]. Today, there is a lack of evidence concerning how RTW can be facilitated among these women. It is known that previous episodes of sick leave due to CMDs, co-morbidity, educational level, age, perceived health, hours of sleep per night and employers’ support affect RTW among individuals with CMDs [
2,
6,
10]. Regarding current knowledge about RTW interventions, the most effective intervention among persons with CMDs is contact with the workplace during sick leave, preferably in combination with organizational changes, gradual RTW or psychological therapy [
16]. This is part of what is called the Rehabilitation Chain in Sweden [
17], where the employer is obligated to establish a RTW plan that is adjusted to the employee’s needs, if possible [
18]. However, these interventions are not flexible enough to address needs related to all disorders among the CMDs [
16], and long-term sick leave due to CMDs is still a growing problem in society. Therefore, new, preferably theory-driven [
7,
19,
20] research in the area of CMDs and sick leave is called for. Regarding women, for whom evidence-based interventions are most urgent because they are the most vulnerable group, the lack of knowledge is even greater.
One overlooked aspect of RTW after long-term sick leave due to CMDs is the individual’s own intention to RTW [
7], which has been shown to predict RTW among persons with musculoskeletal disorders [
21]. The term “intention” is similar to, and even used synonymously with, the more common concept of “expectation” [
21]. It is well known that RTW expectation does predict time to RTW among individuals on sick leave due to CMDs [
7]. There has, however, been criticism of both the fact that RTW expectations are measured narrowly and differently in different studies, and of the fact that there is a knowledge gap regarding the basis for RTW expectations [
7]. It is therefore suggested to move forward by investigating the broader concept of RTW intention in relation to RTW among individuals with CMDs, and to do so using a more consistent measurement based on theory [
7]. An appropriate theory for doing this is the Theory of Planned Behaviour [
8].
This theory is well-suited to investigating the intention to perform a behaviour and has been able to explain the importance of intention for various behaviours [
22,
23], but rarely in relation to RTW. According to the Theory of Planned Behaviour [
8], a strong intention to perform a behaviour leads to actual performance of the behaviour. Intention is defined as the degree to which a person is motivated or willing to perform a behaviour or his/hers readiness to execute the behaviour [
8]. When measuring intention according to the Theory of Planned Behaviour, using a combination of items on intention, expectation and willingness to perform a behaviour is common [
24].
Moreover, intention is based on underlying beliefs regarding the behaviour, which are essential to identify before predicting the actual behaviour [
8]. These beliefs are three conceptually independent determinants: the individual’s own attitude towards, subjective norms (i.e., social pressure) and perceived behaviour control over a behaviour. Underlying these determinants are salient beliefs: behavioural beliefs (attitude), normative beliefs (subjective norm), and control beliefs (perceived behavioural control). Behavioural beliefs concern the advantages and disadvantages believed to be associated with the behaviour. Normative beliefs concern beliefs about important people in the individual’s life who will support or not support the performance of the behaviour. Control beliefs concern the believed barriers to and facilitators of performing the behaviour [
24]. Dunstan et al. [
21] found that behavioural beliefs, normative beliefs and control beliefs all showed a significant positive relationship with RTW intention among individuals with musculoskeletal disorders, which often co-occur with CMDs [
25].
Regarding CMDs, they entail various physical and mental symptoms that decrease interest in things in life and the motivation to act [
26]. A qualitative study, based on the Theory of Planned Behaviour and conducted on women on long-term sick leave due to CMDs, identified that symptoms from the CMD were perceived as barriers to RTW [
27]. Based on this, it is reasonable to take psychological well-being and perceived health into account when identifying determinants of RTW intention among women on long-term sick leave due to CMDs. This is supported by the recommendation to include additional determinants that may increase the explanatory power of the intention, when using the Theory of Planned Behaviour [
8].
Using the Theory of Planned Behaviour, including psychological well-being and perceived health, is a way of filling the gap in our knowledge about what underlies RTW intentions among women on long-term sick leave for CMDs. This provides a base for future prediction of actual RTW, as well as increasing our understanding of determinants of RTW intention in this group. Because women are most affected by long-term sick leave due to CMDs, there is value in studying them separately. This makes it easier to draw conclusions about the most vulnerable group, which is the most urgent to target. Thus, the present study aimed to identify associations between RTW beliefs, psychological well-being, perceived health and RTW intentions among women on long-term sick leave due to CMDs, and did so using the Theory of Planned Behaviour as its theoretical base.
Discussion
The results showed that women had strong RTW intentions, but low psychological well-being and perceived health. They had positive attitudes towards and strong social pressure to RTW, but perceived relatively low control over it. Positive attitudes towards RTW, strong social pressure to RTW, high perceived behavioural control over RTW and high psychological well-being were associated with a stronger intention to RTW. However, when potential confounders were included in the analysis, psychological well-being was no longer significantly associated with RTW intention. Instead, women who reported that their employer had taken actions to facilitate their RTW had stronger RTW intention.
The result showed that a positive attitude towards RTW was the most important determinant of a strong RTW intention. This is in line with earlier research among individuals with musculoskeletal disorders [
21]. In the present study, the correlations between indirect and direct measures (Table
3) showed that better health and meaningfulness were the strongest indirect measures within the attitude. This means that if the women believed that RTW would result in better health and a feeling of meaningfulness, and that this was important to them, they were more likely to have a positive attitude towards RTW. This emphasizes the importance of health-promoting workplaces, which is described by the World Health Organization as a priority setting for health promotion in the twenty-first century [
42]. This involves, for example, meeting the needs of employees and developing the positive aspects of work as well as the strengths of the individual employees [
43]. Based on this, it may be important to provide the women with work tasks that correspond not only to their current capacity, as described in the “Rehabilitation Chain” from the SIA [
17], but also to their interests and ideas about what constitutes a meaningful job.
Furthermore, the results showed that women who perceived strong social pressure to RTW had higher RTW intentions. However, earlier research has shown that depression symptoms may increase when the individual is perceiving social pressure to feel better [
44]. Table
3 shows that social pressure from family/relatives had the strongest correlation with the subjective norm, i.e., that pressure from the women’s family was most important to the feeling of social pressure to RTW. This is in line with findings showing that women more often experience a family-work conflict [
13]. More research is needed to investigate the role of social pressure for RTW intention among women within different family constellations. For example, are there different determinants of RTW intention among single women than among married women with children?
Moreover, stronger perceived behavioural control over RTW was significantly associated with stronger RTW intention. Interestingly, the women in the present study had a job to return to (which might be seen as a part of
actual control as described by Ajzen [
8]), but according to the descriptive statistics in Table
2, they perceived relatively low control over RTW. This discrepancy may indicate that the women did not feel they had control over their CMD symptoms, which in turn affects the ability to RTW [
6]. The indirect measures that were most strongly correlated with perceived behavioural control were the barrier “worsened health” upon RTW and the facilitator “having well-adapted working tasks that one can perform at one’s own pace”. One interpretation of this finding is that planning for and providing individualized work tasks are needed to reduce the barrier entailed in the belief that one’s health will worsen upon RTW.
Furthermore, women with high psychological well-being had stronger RTW intention. It is known that symptom burden is an important predictor of RTW among persons on sick leave due to CMDs, i.e. lower symptom severity is associated with earlier RTW [
6]. However, when adding potential confounders to the analysis, psychological well-being was no longer significantly associated with RTW intention. Instead, the employer’s effort to facilitate the woman’s RTW emerged as a significant factor. In other words, women who reported that their employer had taken actions to facilitate RTW had stronger RTW intention. Previous research among persons with CMDs has shown similar results, indicating that employer support is an important factor for RTW [
6]. Over a third of the women in the present study reported that their employer had not taken actions to facilitate their RTW. In Sweden, employers are obligated to plan RTW-facilitating adjustments for individuals on long-term sick leave (> 60 days) [
18]. The plan is to be made together with the individual on sick leave. More research is needed to investigate why a large number of women reported a lack of facilitating actions on the part of their employer. Moreover, it is not clear whether it is the actions per se that are important, or whether it is the social support signified by such actions. Previous research has indicated that the social aspect of employer support is more important than characteristics of the work itself [
45] as well as which aspects of employer actions matter for RTW intention.
Perceived health was not significantly associated with RTW intention in the present study. One explanation may be the high correlation between psychological well-being and perceived health in the analysis. It is important to keep in mind that, in the present study, the most crucial aspect of having a positive attitude towards RTW among the women was the belief that their health would improve upon RTW. Hence, current perceived health seems to be less important to RTW intention than is the belief that one’s health will improve in the future.
In summary, using the Theory of Planned Behaviour, a range of determinants of RTW intentions have been identified. This is relevant to health care professionals, employers and other stakeholders involved in the RTW process. However, the relationship between RTW intention and actual RTW among individuals on long-term sick leave due to CMDs is not known, but it is well known that RTW expectation does predict actual RTW in this group [
7]. Supplementary material in the current study reveals that RTW expectation shows the same pattern as RTW intention, which makes it reasonable to assume that RTW intention is relevant for actual RTW as well. Moreover, because this is a cross-sectional study, no cause-and-effect conclusions can be drawn. Longitudinal research is the next natural step in exploring the importance of RTW beliefs, psychological well-being and perceived health for actual RTW. Furthermore, additional psychometric properties of the RTW Beliefs Questionnaire must be tested to evaluate the instrument’s validity and reliability in more detail.
Methodological considerations
The present study has some limitations. First, it had a relatively small sample size and a low response rate. This may be due to symptoms related to CMDs; i.e., concentration difficulties or feelings of exhaustion may make completing comprehensive questionnaires challenging. Because of this, we may have missed the women most affected by CMD symptoms. One strength of the selection process was that participants were selected based on a diagnosis issued by a physician and not on the women’s own opinions about why they were on sick leave. However, the sample may be considered heterogeneous due to the varying degree of sick leave (25–100%). It is reasonable to assume that there are differences in RTW beliefs between women who are on full-time sick leave and those who work to some extent. However, because the target behaviour of the present study was RTW, we argue that it was appropriate to include all of them. The RTW Beliefs Questionnaire is a new, theory-based instrument, developed especially for women who are on sick leave for CMDs. To our knowledge, no similar instrument exists, and thus it is considered to make a valuable contribution to the field. However, it needs to be tested further regarding its psychometric properties. What we know thus far is that one of the sub-scales, subjective norm, showed poor internal consistency. If this had been a more stable construct, the results might have given a more accurate picture of its association with RTW intention. However, the results were in line with previous research [
21], showing that subjective norm was positively associated with RTW intention, which is why we believe the overall results are valid. Further research is needed to evaluate the problem with the scale of a subjective norm among women on long-term sick leave due to CMDs, i.e., why it is heterogenous and how the scale should be used most accurately. For example, social pressure from “important people” may be more crucial to RTW intention than is social pressure from undefined “others”. Furthermore, the representativeness of the sample may be questioned. Unfortunately, a non-response analysis was not possible to perform, but nationally, sick leave > 14 days due to mental disorders among women is most common in the age group 35–44 years [
2]. The mean age in the present study was somewhat higher, which calls into question the generalizability of the results. Moreover, the sampling was done in a rural area in Sweden with no big cities, which may negatively affect generalizability, as there are different kinds of social support and surroundings in big cities that may influence the experience of being on sick-leave due to CMDs [
1]. However, a large proportion of the included women worked in the health or social care sector, which is in line with the occupations of women on sick leave for CMDs nationally [
2]. Caution is in order when generalizing to persons not born in Sweden, however, as only 7% of the women in the present study were born abroad.
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