Every year many individuals became sick listed, it could be for a long time, or a short time but irrespective there will be effects on the individuals life and on the society. The aim of this study was to describe some relevant psychosocial relationships in the workplace that effect that women become sick listed. The method of the study was a literary study which was based on a number of scientific articles. The result of the study showed that many different factors effects the risk of becoming sick listed. Factors that causes sick leave where many and individual, but lack of social support, bullying, unstructured work environment and the workplaces management, imbalance between demands and control and the women's situation were factors that had a big influence. Women had the greatest number of sick leave, and for a better answer to why it is mostly women who are sick listed more research is needed. The answer we found was that it was not about the sex, it was more about where you work or in which profession you are. To reduce the number of sick listed, big achievements are needed from the individual, the employer and the society. More research on how to reduce the number of people on sick leave is also needed.

Bakgrund: Sjukfrånvaron i Sverige 2004 var högst i Västeuropa och landets enskilt största ekonomiska problem. Regeringen vidtog åtgärder för att minska sjukfrånvaron. En del var att ge incitament för att sjukskrivningsprocessen skulle finnas med i hälso- och sjukvårdens ledningssystem, delvis på grund av förändrade krav och därmed brister i läkarintygens kvalitet. En lokal undersökning vid ortopedkliniken Kärnsjukhuset visade att 23 % av patienterna var missnöjda i samband med sjukskrivning. Syfte: Genom Sex Sigmas problemlösningsmodell DMAIC i kombination med mikrosystemperspektivet förbättra kvaliteten på läkarintygen, skapa mål och rutiner i sjukskrivningsprocessen samt öka patientnöjdhet  Metod: Utifrån ett mikrosystemperspektiv intervjuades projektgruppsdeltagare. Genom Sex Sigmas problemlösningsmodell fokuserades förbättringsområden på informationsutbyte till patienter och läkare samt utformande av mål och skriftliga rutiner. Femtioåtta patienter intervjuades om hur nöjda de var med sin sjukskrivning. Mätningar av ”onödiga” åtgärder utfördes och kvaliteten i läkarintygen följdes med styrdiagram. Förbättringsprojektet utvärderades kontinuerligt genom reflektion i projektgruppen. Resultat: Förbättringsarbete med hjälp av Sex Sigma och mikrosystemperspektiv har bidragit signifikant till ökad kvalitet i läkarintygen, p<0,001. Rutiner och mål för sjukskrivningsprocessen har implementerats i ledningssystemet. Hundra procent av patienterna på ortopedkliniken är nöjda och telefonsamtal om brister och felaktiga ärenden har minskat. Förbättringsmetodiken har bidragit till ett vidgat synsätt, ökad förståelse för patienten och mellan personalkategorier. Åtgärderna har haft genomslagskraft genom att förbättringsförslagen kom från dem som arbetar i verksamheten och genomfördes med egen personal. Diskussion: Sex Sigma och mikrosystemperspektivet har patientfokus vilket kan påverka värderingar och vilja till förändringar. Resultatet från denna studie stöder det som kommit fram i andra studier och arbetssättet gav signifikant förbättrat resultat. Förbättringsåtgärderna är inte generaliserbara men arbetssättet kan med fördel tillämpas i förbättringsarbete. Ytterligare studier av arbetssättet och dess hållbarhet över tid behövs för att stärka evidensen. / Background: The sickness absence in Sweden 2004 was highest inWestern Europe and the country's main economic problem. The government gave incentives to make the sick-leave process included in healthcare management system, partly because of changing requirements and deficiencies in the quality of medical-certificates quality. A local study at an orthopedic clinic showed that 23% of patients were dissatisfied with sick-leave. Purpose: Through Six Sigma's DMAIC problem-solving model in combination with micro-systems perspective, improving the quality of medical certificates, create goals and routines in the sick-leave process and increase patient satisfaction Method: Interviews of project participants were carried out using a micro-systems perspective. Through Six Sigma problem-solving model areas of improvement were focused on information exchange to patients and physicians as well as formulating goals and written routines. Fifty-eight patients were interviewed about their sick-leave satisfaction. Measurements of "unnecessary" actions were performed and the quality of medical certificates was followed with control-charts. The improvement project was evaluated by reflection in the group continuously. Results: Improvements with Six Sigma and micro-systems perspective has contributed to improving the quality of medical certificates significantly p<0.001. Routines and goals for sick-leave process have been implemented in the management system. 100% of the patients at the orthopedic clinic are satisfied. Phone calls about deficiencies and incorrect cases have decreased. This methodology has contributed to a broadened understanding of patients´ experiences and between different staff-categories. The actions have had impact because the improving proposals came from and were carried out by its own staff. Discussion: The Six Sigma and the micro-systems perspective has patient focus which can affect the values and willingness to change. The result from this study supports other studies and the approach in this study resulted in significantly improved results. Improvement actions are not generalizable, but the approach can be usefully applied in improvement efforts. Further studies of the approach and its sustainability over time are needed to strengthen the evidence.

Bakgrund: Personer med muskuloskeletala och psykiska diagnoser står för 57 % av sjukskrivningarna i Västerås. Majoriteten av dessa är kvinnor. Det har blivit vanligare att man, vid rehabilitering, förutom personens fysiska funktion även beaktar psykiska aspekter, så som copingstrategier. Syfte: Att kartlägga de mest förekommande copingstrategierna hos personer som varit sjukskrivna mellan 3 och 6 månader och att undersöka eventuella skillnader i copingstrategier mellan män och kvinnor samt mellan personer med psykiska och muskuloskeletala besvär. Metod: En enkätbaserad deskriptiv tvärsnittsstudie genomfördes. Urvalet var ett bekvämlighetsurval som rekryterades i samarbete med Sjukskrivningskommittén och Försäkringskassan i Västerås. Åttio personer tillfrågades om deltagande varav 40 personer var sjukskrivna på grund av psykiska besvär och fyrtio på grund av en muskuloskeletala besvär. Resultat/Slutsats: Tjugo personer deltog i studien. Av dessa var 17 kvinnor och 3 män, 16 personer hade muskuloskeletala besvär och 4 psykiska besvär. De mest förekommande copingstrategierna inom gruppen långtidssjukskrivna var att öka aktivitet, smärtbeteende och självstärkande. Det är vanligare med katastroftankar hos personer med muskuloskeletala besvär än hos personer med psykiska besvär. Ingen skillnad mellan män och kvinnor kunde analyseras eftersom könsfördelningen bland deltagarna var ojämnt fördelad. Det går ej att dra några absoluta slutsatser utifrån resultatet på grund av det stora bortfallet och det låga deltagarantalet. / Background: People with musculoskeletal and mental disorders account for 57% of sick leave in Västerås. The majority of these are women. It has become more common in rehabilitation that also to take into account psychological aspects, such as coping strategies. Objective: To identify the most prevalent coping strategies in persons on sick leave between 3 and 6 months and to analyze possible differences in coping strategies between men and women as well as between people with mental and  musculoskeletal disorders. Method: A questionnaire-based descriptive cross-sectional study. A convenience sample was invited to participate the sample was recruited in cooperation with Sjukskrivningskommittén and Försäkringskassan in Västerås. Eighty persons were asked for participation of which 40 were on sick leave due to mental disorders and 40 due to musculoskeletal disorders. Results/Conclusion: Twenty people participated in the study. Of these were 17 women and three were men. Of those, 16 people had a musculoskeletal disorder and four had a mental disorder. The most prevalent coping strategies within the group long-term sickness was increasing activity, pain anxiety and self-reinforcing. People with musculoskeletal disorders had more catastrophizing thoughts than people with mental disorders. No difference between men and women were possible to analyse because the gender distribution among the participants were uneven. The small sample size and high drop- out rate does not allow any absolute conclusions based on the study results.

Background: The recent increase in long-term sickness absence both in Sweden and many other countries has been met with various attempts to intensify the use of rehabilitation measures in order to prevent people from remaining long-term sickness absent. Several actors, among them professionals in healthcare, occupational health services, and social insurance are involved in handling issues related to the sick leave of an individual, and in providing measures to promote return to work (RTW). Identification of the factors that are related to RTW of the individual is a multifaceted task; therefore to meet the individual in this process is an essential challenge for many actors involved. Knowledge is needed about factors that might promote RTW in order to facilitate future research aimed at designing effective rehabilitation programs. Such information is of great importance to improve the work situations of the professionals, to decrease the cost for society, and to improve the situations for people on sick leave by facilitating RTW. Objectives: The overall aim of the work underlying this thesis was to ascertain whether contacts between professionals and sickness absentees might a factor that can promote RTW, and also to identify different aspects of how such positive encounters are experienced by those who are sick listed. Material and methods: Five investigations were conducted using different study designs, data, and methods of data analyses. The first two (papers I and II) concerned interviews with people on sick leave about positive experiences of their encounters with professionals. The third study (paper III) was based on four questions about encounters, which were included in a questionnaire that was administrated to people who were on sick leave. The fourth study (paper IV) used a broad questionnaire to examine experiences of positive encounters, and the final study (paper V) proposed a model of possible effects of the encounters on RTW. Results: In paper I and II different aspects of sick-listed person’s experiences of positive encounters were identified. For example, it seemed that important qualities included being treated with respect, feeling supported, establishing a personal relationship, and participating in decisions regarding RTW measures. Several of the interviewees stated that RTW might be promoted by positive encounters. Paper III showed that perceptions of interactions varied with the type of professionals, as well as with demographics. The respondents perceived their encounters with professionals within healthcare as most positive, followed by social insurance, and lastly occupational health services. In general, females, people born in Sweden, and those who were older, or had a higher education rated their encounters with professionals as more positive. The main finding reported in paper IV was that the majority of the participants had experienced being positive encountered by professionals. Three aspects of such encounters were stressed, namely being treated with ”competence”, ”personal attention”, and ”competence and trust”. The results related in paper V indicated that theories about empowerment and on social emotions could be successfully applied in this area, after they were specifically adapted to some unique features of the contacts between sickness absentees and rehabilitation professionals. Conclusions: This thesis emphasizes that being positively encountered by professionals can have a beneficial impact on RTW after a period of sickness absence. More research is required to elucidate the interaction between sick-listed persons and professionals who are involved in their cases. Further studies should focus on how methods for professionals can be provided to increase sick-listed persons’ own ability to mobilize and develop their resources. Moreover, additional knowledge is needed to extend professional treatment strategies that enhance self-confidence and empowerment of individuals during sickness absence.

Background. In Sweden 10 percent (550,000) of the labour force, aged 18 to 65 years are disability pensioners and about four percent are on sick leave. The knowledge of the course from healthy individual to disability pensioner is not well known and was the theme of this thesis. Objectives, Material and Methods. The aims of the thesis were to follow the study population regarding sickness absence, health care utilisation, quality of life, and survival. Population based data including 14,538 women and men from three cities in Sweden were used, of whom 1,952 were granted a disability pension at baseline or received one during follow up. Register data, including sickness spells, health care utilisation, and mortality data during 30 years of follow up, and questionnaire data including socio-economic and quality of life data were used. Results. The most powerful determinant for being granted a disability pension was cumulative annual sick leave days, more powerful than all other tested determinants together. The degree of explanation for all determinants combined was 96%. Health care utilisation among disability pensioners continued to be high also after disability pension, 2.3 times higher for hospital admissions and 8 times higher for primary health case appointments than among referents. Disability pensioners had lower quality of life than non-pensioners and old age pensioners. For those who became disability pensioners after the baseline measurements quality of life measures decreased progressively until disability pension was granted and were then stabilised on a low level. During follow up 525 (7.6%) subjects died. Compared with subjects who did not become disability pensioners the hazards ratio was 2.78 among women and 3.43 among men, even when the effect of a number of other outcome affecting variables were taken into account. The mortality differences were not explained by underlying disease. Conclusions. The risk of disability pension may be predicted but only late in the course of events. Disability pensioners continue to have a high level of health care utilisation, and have a worse quality of life development and a higher mortality rate than non-pensioners. Given the unfavourable outcome of disability pension, other means of managing the reduced work capacity might be considered.

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Stressrelaterad psykisk ohälsa ökar mest och står för den längsta varaktigheten bland sjukskrivningarna. Förändringar i sjukförsäkringssystemet och beslut om att minska sjuktalen har gett konsekvenser som ökat antal avslag om sjukpenning. Syftet med studien var att undersöka erfarenheter av avslag om sjukpenning från Försäkringskassan hos personer med stressrelaterad psykisk ohälsa för att beskriva och förstå vad det får för betydelse för deras sjukdomsbild och återhämtning. Studien är kvalitativ och har genomförts genom semistrukturerade intervjuer med fem personer som drabbats av stressrelaterad psykisk ohälsa och fått avslag om sjukpenning från Försäkringskassan. Materialet som samlats genom intervjuerna har analyserats med Ulrich Becks teorin om risksamhället och Randall Collins teori om symboliska interaktionskedjor samt tidigare forskning. Resultatet i studien indikerar att avslag om sjukpenning påverkar sjukdomsbilden och möjligheten till återhämtning negativt för personer som drabbats av stressrelaterad psykisk ohälsa. Respondenterna upplevde att avslaget förlängt sjukdomstiden, genom minskad möjlighet till återhämtning och förvärrad sjukdomsbild. Resultatet visar även på en samlad bild av upplevelsen av avslaget om sjukpenning från Försäkringskassan. Personerna upplever inte att handläggare på Försäkringskassan tror dem och därmed känner de sig kränkta. / Stress-related disorders have increased and accounts for the longest duration of sick leave. Changes in the health insurance system and decisions to reduce the sick-leave have had consequences such as an increased number of rejection of sickness benefits. The aim of this study was to investigate the experience for people having a stress-related disorder and being rejected sickness benefits from the Social Insurance Fund, to describe and understand the importance for their disease image and recovery. The study is qualitative and has been conducted through semistructured interviews with five participants who suffered from stress-related disorders and received a refusal of sickness benefits from the Social Insurance Fund. The material gathered through the interviews has been analyzed with Ulrich Beck’s theory of risk society and Randall Collin’s theory of symbolic interaction-chains and previous research. The result of this study indicates that the refusal of sickness benefits affects the recovery rate negatively for the participants in the study. The participants felt that the refusal extended the disease time, and they experienced reduced opportunities to recover and a worse diseases image. The result also shows a consistent picture of the experience of receiving a refusal of sickness benefits from the Swedish Social Insurance Agency. The participants do not feel that the case officers at the Social Security Fund believe them and thus they feel offended.