Subjective health complaints (SHC), such as musculoskeletal and mental health complaints, have a high prevalence in the general population [
1,
2]. SHC refers to complaints without a pathophysiological explanation or where the pathological findings are disproportionate to the illness experience [
3]. The complaints can be very troublesome, affecting the ability to function both at work and in social settings.
Non-specific musculoskeletal complaints and mental health complaints present a major public health problem and a high economical burden in western societies [
4‐
6], and are the most frequent reasons reported for sick leave [
7‐
9]. Sick leave is a multi-causal phenomenon and there are different opinions regarding which factors are most important for sick leave (e.g. [
10‐
13]). However, there is considerably more consensus regarding the negative consequences of long-term sick leave, both in terms of the major costs for society and organisations and the serious consequences it may have for the individual (e.g. [
5,
14,
15]). Accordingly, it is important to gain knowledge about effective interventions to prevent and reduce long-term sick leave - both from a societal and an individual perspective.
Preventing the occurrence of SHC is difficult, or may not even be possible. These common complaints seem to be inherent in human nature and a part of everyday life, regardless of society or modern civilisation [
16‐
18]. However, it may be possible to influence the employees’ perception and management of SHC, which in turn can have impact on sick leave and return to work after sick leave [
19].
Non-specific musculoskeletal disorders
Non-specific musculoskeletal disorders refer to pain or discomfort where it is not possible to identify an underlying cause of the pain, and back pain (BP) is the most common musculoskeletal complaint [
20]. A multitude of treatments have been developed for the prevention of BP, but the results have been disappointing [
20]. It seems difficult to prevent acute non-specific BP, but the consequences of the BP, such as fear of injury or activity, inactivity, and/or sick leave may be prevented [
20]. Development of maladaptive perceptions about the cause and prognosis of BP is associated with a poorer clinical outcome [
21]. The prevention of the negative consequences of BP can thus be seen as a way to improve the long term work participation for employees with BP, as well as decreasing the risk of the BP becoming chronic.
Brief Interventions (BI), based on the ‘non-injury model’ proposed by Indahl [
22‐
26], have been among the most successful approaches to increase return to work for employees with BP [
24,
25,
27‐
29]. According to this model, the spine is a strong and robust structure. Pain is not a sign of injury to the spine caused by any wrongdoing or ‘inappropriate’ behaviour. When a patient has the perception that the BP is caused by an injury to the spine and that the spine is likely to deteriorate with activity, inactivity is a rational choice. In the BI this illness perception [
30] is challenged by presenting a perception of BP as a painful, but benign and usually self-limiting condition. The treatment providers’ job is not to ‘cure’ the pain, nor to remove fear of activity, but simply to present the evidence for the benefit of being active [
31] and let the employee decide how to make best use of the information. The intention is to replace any maladaptive previous perceptions of BP. This non-injury model is consistent with the understanding and recommendations in the European Guidelines for the prevention of BP [
20].
Common mental disorders
Anxiety and depression are often termed ‘common mental disorders’ (CMD), because of their high prevalence, affecting 20–25 % of the adult population [
32‐
34]. CMD has emerged as a major public and occupational health problem in many countries [
5,
35]. Depression and mild anxiety are the most common mental disorders among employees [
35,
36]. As with other mental disorders, the core symptoms of anxiety and depression affect a person’s emotional, cognitive and social functioning, which also may have impact on the capacity for work [
37]. The increase in sick leave and work disability because of CMD has serious negative health and economical consequences calling for prevention [
38‐
40]. Although mental disorders has become one of the greatest new social and labour market challenges in the OECD countries, little is known about the underlying causes of this phenomenon [
9]. The most straightforward explanation would be an increase in the prevalence of mental disorders, but that does not seem to be the case. Most of the studies that have examined this, find limited evidence to suggest an increase in the prevalence of mental disorders over time (e.g. [
41‐
45]). It appears that the increased awareness of complaints that have always been there without really being acknowledged, also has led to more exclusion from the workforce for these problems [
9].
There is a high degree of comorbidity between CMD and BP [
46‐
48]. In the general population persons with BP are more likely to report CMD than persons without BP [
48,
49], and few pathological findings by physical examination in patients with BP are associated with more psychiatric symptoms than for patients with an identified structural or organic cause for the BP [
50,
51]. However, the relationship seems to work both ways; BP can precede CMD, and CMD can precede BP [
52]. Interventions targeting both BP and CMD should consider the high comorbidity between these conditions.
There is evidence that cognitive behavioural therapy and psychoeducational treatment for risk groups and individuals in an early stage of anxiety and depression may be effective [
53‐
56]. However, reaching the majority of the population who are at risk of these disorders are difficult, because most people do not seek help until their problems are well advanced or do not seek help at all [
57,
58]. Thus, population-based health promotion and prevention interventions targeting CMD may be useful, because it may be provided to everyone at risk, including those with no or very low risk. Population-based interventions are also found to be the most cost-effective interventions [
59]. The workplace is an ideal setting for such population-oriented prevention programs [
60,
61]. Distributing knowledge about CMD at the workplace, expressed with respect for the participants, delivered in a way that normalises but at the same time does not trivialise the complaints, presents an opportunity to overcome widespread stigma and fears concerning CMD. Stigma and self-stigma is still prevalent across the OECD countries [
9].
Social support and coping skills are important factors to increase resistance to development of mental disorders [
54,
62,
63]. Prolonged stress activation as a result of lack of coping might lead to feelings of helplessness and hopelessness, both proposed as cognitive models of depression [
64‐
66]. Coping seems to be a stronger predictor for health than socioeconomic status [
67,
68], and interventions aimed at targeting these factors can be expected to produce benefits to employees’ mental health, and further induce a beneficial effect on organisational health. Interventions providing information about mental health and illness report significant gains in knowledge, improved health, greater confidence in seeking help and providing help to others, decreased stigmatising attitudes, increased use of positive coping strategies, and improved social skills [
69‐
74].
The atWork intervention
atWork was established in 2007 as a new stepped-care approach to musculoskeletal complaints [
19]. The intervention consisted of three workplace information meetings about BP to all employees, in addition to peer support. The atWork intervention targeting BP reduced sick leave and myths about BP in a randomised controlled trial (RCT) [
19]. After this RCT the atWork intervention has been further developed with the goal to increase effect on health related measures. Because of the high comorbidity between BP and CMD, the high prevalence and the negative consequences of CMD, the atWork intervention has been modified to also comprise mental health complaints. A management seminar is also included, aiming to increase manager involvement and knowledge about the message distributed in the intervention.
atWork is a cognitive workplace intervention, based on the BI and the non-injury model [
23‐
25]. atWork uses the workplace as an arena for health promotion. By focusing on altering employees’ beliefs and behaviour through evidence-based health information, atWork aims to enable employees to cope with the consequences of their health complaints [
19]. This is done by providing insight and understanding of BP and CMD to all employees and managers, based on the non-directive social support model [
75] and peer support [
19]. atWork also has a theoretical foundation from the Cognitive Activation Theory of Stress (CATS), where coping is defined as a positive response outcome expectancy, a belief that your actions or strategies will lead to a positive result [
66]. In addition to reaching out to all employees with the intervention, the aim of atWork is to reinforce an organisational culture where workers with health complaints are accepted as part of the normal work environment.