Study design
A controlled before-and-after study with a follow-up period of 6 months will be conducted. Students with extensive medical absence attending schools in which the MASS intervention has been implemented (intervention group) are compared to students attending schools in which the MASS intervention has not been implemented (control group).
The Medical Ethical Committee of Erasmus University Medical Centre Rotterdam has declared that the Medical Research Involving Human Subjects Act (also known by its Dutch abbreviation WMO) does not apply to this research protocol and issued a declaration of no objection (i.e. formal waver) for this study (MEC-2015-614). Therefore, the study can be carried out without further approval by an accredited research ethics committee.
Procedure
Participating schools are visited by the Erasmus MC researchers to explain the procedure of the study. The schools (usually an appointed coordinator) select students meeting the inclusion criteria (i.e. reported sick for at least four times in 12 weeks or reported sick for more than six consecutive school days) and invite them to participate in the study. All students receive an information letter and leaflet with information about the study. They are asked to provide informed consent. Participants in the study are invited to complete the baseline questionnaire. The coordinator will send the filled-out questionnaires back to the researchers on a regular basis. For students aged younger than 18 years of age qualifying for participation, parents also receive an information letter and brochure about the study at home provided by school; these parents can object to participation in the study by their child. After 6 months, a follow-up questionnaire will be sent to the students. Students will receive either a hard-copy version, a digital version or both versions, depending on their preference.
Students in intervention schools who have a consultation with the YHC professional will be asked by the YHC professional to complete an additional short questionnaire after consultation. The YHC professionals themselves are also asked to fill out a short questionnaire after each consultation. All questionnaires are to be dropped in sealed envelopes in a drop box which will be located at an agreed upon location with the coordinator of the school. The coordinator will send the questionnaires back to the researchers on a regular basis.
Data will be processed in accordance with the agreed guidelines of the Dutch Data Protection Authority Intervention [
30].
Intervention
Intervention group: the MASS intervention
The MASS intervention designed for intermediate vocational education schools consists of five steps: an active approach by the school after the first sick report, a meeting between student and school, a YHC professional referral if needed, the actual YHC professional consultation, and the further monitoring of the medical absenteeism and reintegration of the student [
31] (Table
1).
Table 1
Description of the key steps of the MASS intervention
1 | The school contacts the student actively in case of medical absence and asks about the context of the sickness report and condition of the student. |
2 | The school organizes a meeting with the student (and parents if student is <18 years old) in case of extensive medical absenteeism (criteria predefined by each individual school, apart from the MASS criteria). |
3 | The school refers the student to a YHC professional if considered to be needed. |
4 | A YHC consultation between student and YHC professional is organized |
5 | The school is responsible for monitoring the medical absenteeism and school-related implementation of the reintegration plan, if created. |
The intervention focuses at two levels; the school level and the individual level. The implementation of the MASS intervention at school level includes agreements on how to actively monitor student absence, approach students with extensive medical absence by personal contact, request a consultation with the YHC professional, and arrange a follow-up for each student in the Care Advisory Team (CAT). The CAT includes social workers, attendance officer, YHC professionals, teachers and a Youth Care Office representative.
At an individual level students with extensive medical absenteeism will be identified by school and referred to YHC if needed. In the consultation, the YHC professional focuses on somatic, psychological and social factors potentially underlying the medical absenteeism (Table
2). Along with the student, and the parents if the student is younger than 18 years of age, a reintegration plan is formulated. Whichever reintegration plan is chosen, the YHC professional is accountable for the referral, the aftercare, communication with other care professionals, communication with the adolescent and monitoring the procedure accurately. All YHC professionals are trained in performing the MASS protocol [
31].
Table 2
Description of key elements of the YHC consultation
1 | The YHC professional and the student conduct a problem analysis |
2 | The YHC professional analyses the underlying problems by use of the biopsychosocial model |
3 | The underlying causes of the medical absence are defined |
4 | The possibilities of preventing recurrence in the future are discussed |
5 | The possibilities for extra treatments by health care professionals or other supporting professionals are discussed |
6 | An action plan regarding reintegration will be created, if needed |
7 | The YHC professional is responsible for communicating, with the consent of the student, the reintegration plan to all other involved parties without violating his/her professional secrecy |
Control group: care as usual
The control group consists of students attending Intermediate Vocational Education schools that have not implemented the MASS intervention. They continue to provide care as usual using their current absenteeism policy. This generally consists of a referral to a YHC professional on request of the student, when accessible consultation of the CAT and referring to the school attendance officer when student is younger than 18 years old.
Measurements
The following primary and secondary outcome measures were formulated:
Primary outcomes measures
➢ Duration of the medical absence in days within the last 12 weeks at T1 (in comparison with T0).
➢ Cumulative incidence of the medical absenteeism, measured during six months after determining the extensive medical absenteeism.
➢ Academic performances as measured by passing onto the next year or obtaining a basic educational qualification degree.
➢ The extent to which the chosen educational program matches the student’s interests.
Secondary outcome measures
➢ Biopsychosocial problems of intermediate vocational education students after determining the extensive medical absenteeism; it concerns medical, physical, emotional, and psychiatric problems (e.g. depression, anxiety, ADHD), housing, financial problems and contacts in criminal justice.
➢ Realised changes/adjustments in treatment policy by specialists and other involved healthcare professionals for students with depression, anxiety, ADHD and autism spectrum disorders.
Specific outcomes related to the care by YHC professionals.
➢ The extent to which the YHC professionals work in accordance with the MASS protocol assessed during consultation with the student.
➢ Perceived value of the MASS intervention according to the YHC professionals and the students.
Covariates
The covariates are chosen based on comparison of baseline characteristics of intervention and control students. Demographic information regarding the participating students is collected at baseline including ethnicity, SES score, attending school, educational level, and parenthood. Information on a number of known risk factors for school absenteeism are collected at baseline and during follow-up, including age, gender, smoking status, alcohol consumption (abstainer, up to >7 servings/week) and drugs abuse (abstainer, soft drugs, and hard drugs). Biopsychosocial problems concerning medical, physical, emotional, and psychiatric problems (e.g. depression, anxiety, ADHD), housing, financial problems and contacts in criminal justice are included as covariates. Level of physical activity is assessed at baseline and follow-up.
Data collection
Data collection takes place during 1,5 academic school years. All students complete a questionnaire at baseline (T0) and after six months at follow-up (T1). In addition, students in the intervention group complete a questionnaire after consultation with a YHC professional. The YHC professional likewise completes a questionnaire after each consultation with a student in the intervention group. To measure the level of medical absenteeism, data is retrieved from the registration system from school.
The level of medical absenteeism is obtained from the absenteeism registration system from the school in numbers of hours during a period of 12 weeks before T0 and T1; and also during the six months period between T0 and T1. Schools also provide information on the support that was given by the school to the student i.e. school meetings, social work or appointments with the psychologist.
The
baseline questionnaire (T0) contains the following measurements; socio-demographic characteristics, behavioral determinants, mental health conditions, and overall wellbeing. Data on socio-demographic characteristics of the students will be gathered, by including questions regarding gender, age, educational level, country of birth, parents’ country of birth, and home environment [
32,
33]. Behavioural determinants are assessed by questions about school career, physical activity, financial situation, sexual behaviour, smoking, alcohol use and drug abuse. In addition, absenteeism is measured by using the questionnaire based on the questionnaires developed by Municipal Public Health Services and health institutes [
34]. Mental health conditions are assessed by using the Centre for Epidemiologic Studies Depression scale (CES-D) [
35] and the 12-item Short Form Health Survey (SF-12) to measure health-related quality of life [
36]. The CES-D scale is a 20-item scale used to determine the clinical relevance of depression. Selected items will cover the main components of depressive symptoms such as depressed mood, guilt, feelings of inferiority, feelings of helplessness, despair, loss of appetite, sleep and psychomotor retardation [
37‐
39]. The SF-12 questionnaire is used to measure Quality of Life [
36]. Six questions refer to the functional status, including physical and social functioning and physical and emotional limitations. Four questions describe well-being including mental health, vitality and pain. One question relates to the overall health condition. In addition, seven questions are included measuring the duration and incidence of medical absenteeism and truancy as well as the reasons for it.
The questionnaire at follow up (T1) is similar to the baseline questions except for the exclusion of questions on fixed socio-demographic variables and the addition of questions about the satisfaction with the YHC professional consult.
The YHC consultation questionnaire for students consists of 11 items assessing the extent to which the YHC professionals have worked in accordance with the MASS protocol (exposure to intervention). In addition, 10 questions are included measuring the students’ appreciation of the consultation with the YHC professional. Finally students are asked to rate the entire consultation on a scale from 1 to 10, with 1 being the most-negative evaluation score and 10 being the most-positive one.
The
YHC consultation questionnaire for the YHC professionals includes items assessing the extent to which the school (
N = 4) and the YHC professionals (
N = 11) work in accordance with the MASS protocol. In addition, the Dutch version of the self-sufficiency matrix (SSM-D) [
40,
41] is completed by the YHC professionals. The SSM-D addresses the ability of students to provide for themselves regarding 11 specific life-domains (e.g. income, daytime activities, housing, mental health) as assessed by the YHC professional. Each life domain of the SSM is measured by a single item. On each item, students are evaluated on 5-point Likert-type scales, from ‘in crisis’ (1) to ‘thriving’ (5). Finally, the perceived value of the MASS intervention according to the YHC professional including the biological model and the SSM-D, is assessed.
Statistical analyses
In order to evaluate effect of the effect of the intervention the scores on outcomes of both groups measured during follow will be compared, adjusted for baseline findings. For continuous outcome measures such as duration of the medical absenteeism and psychometric test results (multiple) linear regression analyses will be applied. Dichotomous outcomes, such as progressing into the next year or obtaining a basic educational qualification degree, will be evaluated by using a multiple logistic regression analysis.
The research condition will be included as an independent variable. Baseline values of the outcomes are added to the model as covariates. As students are clustered within school locations multilevel analyses will be applied.
Potential moderation of intervention effects by gender, family situation, ethnicity, psychosocial and psychiatric problems (depression, drug abuse, ADHD) is explored by adding an interaction term to the regression models. Stratified analyses will be performed when significant interactions (p < 0.10) are observed.
Experiences of students and YHC professionals with the different elements of the MASS intervention as performed by YHC professionals will be evaluated by performing descriptive analyses.