Comparisons with Other Studies
In previous analysis using partly the same data set [
20], we concluded that participants had lower self-efficacy (mean 2.3) compared to the general population (mean 2.9) [
26,
27]. During the intervention period, the women in the TEAM group showed an increased self-efficacy from 2.29 to 2.74, a level that is not far from observed mean values in the general population.
An earlier study by Lagerveld et al. [
31] on women on long-term sick leave showed that a higher self-efficacy at baseline was associated with a shorter duration to RTW, and that an increase in self-efficacy during an occupational rehabilitation intervention was a predictor for a shorter time to RTW [
31]. In that study, the participants were given CBT to strengthen self-efficacy to support RTW. Beurden et al. [
32] found that participants on sick leave that received an intervention based on cognitive behavioural- and problem solving therapy showed increased self-efficacy at the 3-month follow-up. This suggests that it is possible to strengthen self-efficacy with psychological efforts and that improved self-efficacy may be associated with improved work outcomes.
Lorig and co-workers examined a self-management program based on the sources of information for self-efficacy proposed by Bandura (i.e. verbal persuasion, physiological and affective states, vicarious experiences and enactive mastery) [
1] for patients with arthritis and fibromyalgia [
33]. This study found an increase in self-efficacy at a 1-year follow-up [
33]. We believe that these sources of self-efficacy also was applied in our interventions through the designated person (TEAM member for participants in the TEAM group and psychologist for participants in the ACT group), who supported the participants to reach their goals, by making them aware of their own strengths and abilities. This support could be related to verbal persuasion. Furthermore, the participant’s previous work experiences, opportunities for job adaptation (e.g., assisted by the occupational therapist within the TEAM group) and job training would also have been a possible source for strengthening self-efficacy, related to enactive mastery. Finally, an improvement in the participants’ mental and/or physical condition could conceivably lead to an increase in self-efficacy within both intervention groups, and could thus be connected to psychological and affective states as a source for the judgement of self-efficacy [
1].
Self-efficacy has been found to be negatively associated with depressive symptoms and anxiety [
34], which was also shown in our study. Thus, it is possible that the participants who received psychological treatment with CBT (e.g., ACT) had a reduction of anxiety and depressive symptoms with positive effects on self-efficacy as a consequence. The regulation changes in the social insurance system posed a risk of being outside the compensation system that may have caused stress about the women’s economic situation. This stress may have influenced their self-efficacy negatively. Bandura describes how there is a correlation between the experience of self-efficacy and health, since stress that arises from exposure to events that an individual experiences as uncontrollable can produce biological processes in the body. These biological processes can affect the individual’s health negatively if they are too intensive or prolonged [
1]. The support obtained from the interventions may have reduced this stress.
The team members were educated in MI, a conversation method aimed at strengthening individuals’ motivation and commitment to change. MI is client-centered and builds on cooperation between the adviser and the client, based on partnership, acceptance, compassion and evocation [
23]. One objective of MI is to increase self-efficacy [
35], which has been shown in previous studies, although in areas other than vocational rehabilitation [
36,
37]. However, as it is uncertain to what extent MI was applied in the TEAM intervention, it is not possible to know whether MI had any influence in the increase of self-efficacy found for the women in the TEAM group.
Similar to our study, other studies have also shown that it is possible to strengthen self-efficacy in individuals on sick leave. Hees et al. [
38] showed that weekly clinical management treatment (including psychoeducation, CBT and supportive therapy) solely, and in combination with occupational therapy (OT) (i.e. sessions with an occupational therapist, meeting with the employer, focus on early RTW, improving work-related coping, increase in self-efficacy to improve communication with stakeholders), showed positive effects on self-efficacy in sick-listed with major depression [
38]. Varekamp et al. [
39] showed that self-efficacy increased in individuals with chronic physical diseases who took part in a vocational rehabilitation intervention with the aim to support work maintenance and avoid eventual sick leave. The intervention consisted of a group-training program for problem solving in the work situation and intended to increase the individual’s self-awareness and communication skills at work as well as to find solutions. In our study, the TEAM intervention also had a problem-solving approach to support the participants in their rehabilitation and to increase their likelihood for RTW.
In comparison to the above presented studies whose participants had been on sick leave for a maximum of 1 year [
31,
32,
38,
39], the participants in the present study had been on sick leave for an extremely long time (a mean time of 7.8 years) and may therefore not be fully comparable to other studies. It is reasonable to assume that the participants who had been on sick leave for such a long time needed a more individual orientation of their rehabilitation (including medical, psychological and social aspects) which the TEAM intervention could provide as opposed to the ACT intervention. This difference between the interventions may also explain the lack of improvement in self-efficacy in the ACT group.
To our knowledge, no studies have investigated the possibility to strengthen self-efficacy for individuals on sick leave for such a long time. Furthermore, previous studies have measured self-efficacy using other scales [
31,
32,
34,
38,
39] and in other settings [
34,
39]. General self-efficacy, i.e. an individual’s basic belief in their competence to handle a broad variation of demands in different contexts, is a universal construct that is stable [
25]. This generality makes the strength of general self-efficacy as it can be used in different domains, in comparison to more specific self-efficacy scales [
40]. In addition, we did not explore the association between self-efficacy and RTW, which Lagerveld et al. [
31] and Beurden et al. [
32] did. They used the RTW self-efficacy scale, a specific scale for measuring the change in self-efficacy associated with RTW, which shows stronger associations with RTW compared to the GSE [
18]. Our study showed an increase in general self-efficacy for the women in the TEAM group, although we do not know if they increased their self-efficacy specifically to transition to work.