The OHS guidelines, launched in 2016, were part of a multi-component project aiming to prevent and reduce MSD-related work disability and sick leaves in a large municipal organization. The guidelines aimed to decrease between-physician variation in sick leave prescribing, increase the use of alternatives to full-time sick leave early on, enhance pain management, and influence patients’ pain-related beliefs and attitudes. According to the intervention implementers, the aims had been achieved well. Target physicians, in turn, reported adhering largely to the guidelines and described corresponding behaviours as well as various facilitators of these behaviours. We also identified factors that may have contributed to the observed trends in pain-related sick leaves beyond physicians’ behaviours.
Six of the twelve barriers to key behaviours, identified by the implementers during the initiation of the intervention (e.g. lack of knowledge on the consequences of prolonging sick leaves or doubts about personal capability to handle difficult situations with patients) were not reported as current hindrances to practice by any of the interviewed target physicians. Instead, they described several facilitators of recommended behaviours. It seems that these barriers had been overcome by means applied in the intervention or by external means. However, as we relied on physicians’ self-assessment, it is possible that some barriers identified by the implementers (e.g., routinized practice based on outdated knowledge or forgetting to take account of all relevant factors when making decisions about pain management or sick leave) still prevailed but were not recognized or reported by all interviewed physicians. Some physicians, however, described also means to enhance remembering and reflecting on one’s practice.
Target physicians’ reports of explicit behaviour changes suggest that the intervention achieved its most effects by enhancing physicians’ Psychological capability to engage in recommended behaviours via the intervention functions Education and Enablement. Especially physicians with less working experience described having gained new knowledge and understanding about essential themes from the OHS guidelines. The role of the OHS’s own education may have been larger during the initiation of the intervention. For example, referrals to imaging had been noticed to reduce markedly after the education. However, the majority of the interviewed physicians had started working in the OHS after this education. Physicians’ knowledge has been increased also through learning at work when engaging in new tasks and by other pathways beyond the OHS intervention.
As intended by the implementers, the guidelines were used at least by some interviewees as a reminder of recommended practice and/or a means of self-assessment, i.e., comparing current practice against the guidelines. Physicians appreciated the electronic patient record system, separate from the initial intervention, for guiding them to take a stand on patient’s suitability to alternative work when completing the sick leave prescription.
Physicians identified several facilitators of guidelines-consistent behaviours which were mapped to Reflective motivation and Social opportunity, but for the most part they were not directly related to the intervention received. For example, some physicians explained that they had chosen to work in this OHS because it enabled practicing according to one’s professional goals (preventing work disability, enhancing staying at work/early return to work). Possibilities to multi-professional co-operation and a culture of collegial social support were reported to have prevailed in the OHS even before the intervention. Long-time active collaboration between the OHS and workplaces was seen to result in patients’ and supervisors’ mostly positive attitudes towards the alternatives to sick leave and, thus, facilitate negotiations at the physician’s office. Media campaign targeted to workplaces, as part of the broader OHS development project, was estimated to have a separate positive effect.
Six of the twelve barriers identified initially by the implementers were reported as current hindrances to practice by some target physicians also. Some physicians, especially those with less experience in occupational health care and/or medical practice in general mentioned lack of knowledge. It seems that the intervention has not addressed sufficiently barriers pertaining especially to Physical opportunity. Lack of time to engage in recommended behaviours was experienced especially by general practitioners. Increasing occupational health nurses’ role in chronic pain management may have been insufficient because general practitioners see mostly patients with acute pain. Scarcity of admission hours to occupational physicians concerned some but not all OHS teams. Some physicians recognized non-pharmacological pain treatment tools available in the OHS while others described a shortage of these means, which may be due to lack of information. These results underline the importance of taking into account the needs of different subgroups when implementing an intervention [26, 27]. In addition, process evaluations of ongoing interventions would bring out needs for refinement [19].
We obtained and illustrated data on MSD-related sick leave days prescribed in the OHS before and after the launch of the guidelines using a five-year follow-up period. A descending trend was detected in the number of sick leave days per month especially in low back pain and shoulder pain. However, the effectiveness of the intervention on employees’ sickness absence cannot be evaluated in this study due to the absence of a control group. The results of this analysis are reported elsewhere [34]. However, it seems evident that considerable changes took place during the time period.
Interviewed OHS professionals estimated that the guidelines and related physicians’ behaviours had impacted the observed trend, but they also identified factors beyond physicians’ behaviours, which may have reduced the number of sick leave days: direct access to physiotherapists, good treatment provided by all OHS professionals and enabled by the OHS policy and fairly well-functioning structures and processes, commitment of the client organization to supporting its employees’ work ability, and a cultural change in employees’ attitudes towards absence from work. These factors may also indirectly facilitate physicians’ guidelines-consistent behaviours.
Interviewees also described factors beyond physicians’ behaviours as increasing the number of MSD-related sick leave days, such as structures and processes in primary and special health care, and social insurance. Alternatives to full-time sick leaves are also difficult to carry out in some duties or workplaces, e.g. in heavy manual work.
According to previous studies, primary care physicians found challenging to assess and negotiate the need of sick leave with patients with MSD [3, 4, 35], and sick-listing in general [36,37,38,39]. Physicians reported of personal lack of knowledge, skills and motivation but also of patients and supervisors who were reluctant to suggested alternatives to sick leave. Challenges to recommended sick-listing pertained also to health care organization, e.g., inadequate leadership, insufficient incentives and support for handling sickness certification. In addition, physicians reported of barriers related to societal level, such as long waiting time in health care and inadequate cooperation between different stakeholders in health care and social insurance. Challenges experienced by physicians may result in prescribing unnecessarily long sick leaves [2, 38].
Interventions to promote physicians’ recommended sick leave prescribing may be successful, e.g. encourage them to discuss work with patients or use part-time sickness absence more often [3, 40, 41], but a physician is only one actor in a network of several stakeholders. Targeting physicians only does not, for example, influence the workplaces’ policies for using alternatives to sick leaves. Our results suggest that the OHS has successfully addressed many of the challenges identified in previous studies. Physicians’ capabilities and motivation were explicitly addressed in the intervention but it seems that the OHS provided most interviewed physicians with adequate physical and social environment also. Good long-standing collaboration with the workplaces facilitated engagement in recommended practice. However, also physicians in the present study described societal level barriers to decreasing the number of sick leave days. These factors are beyond the means of interventions implemented by single health care organizations.
Prior studies [17, 42] have presented contradictory results on whether application of various means versus single or few means during an intervention (e.g., dissemination of guidelines, educational meetings, audit and feedback) increased desired physicians’ pain management behaviours. However, instead of trying out different intervention means only, increasing emphasis is now placed on using appropriate theories when developing behaviour change interventions [28, 43]. According to the intervention head designer, the OHS intervention was planned without an explicit behavioural theory but it drew on research on pain management and sickness absence prevention, domestic and foreign pain-related guidelines, and lessons learned from prior interventions among physicians. The designer’s own experience in the field informed which physician behaviours should be targeted, and which intervention strategies are likely to be effective and feasible, given the available resources and the likelihood of acceptance to the physicians. The implementers knew well the OHS staff at that time and the challenges in preventing and reducing MSD-related work disability in this context. Prior studies [13,14,15,16] have also highlighted the importance of identifying and targeting context-specific barriers to desired behaviours.
The declining trend of MSD-related sick leave days prescribed in the OHS levelled off somewhat during the five-year follow-up period. The implementers had noticed variance in the trends of sick leave days especially during summer months suggesting that locum physicians are not introduced sufficiently to the guidelines. In addition, we identified some changes in the intervention process during the follow-up years. Physicians new to the OHS were supposed to be introduced to the guidelines, but not all of our interviewees were familiar with them. Some of the initial intervention components are not in use anymore, i.e., education provided by the OHS, the pain questionnaire to assist physicians in noticing patients with threat of chronic pain, and the pain groups for patients. It seems that no compensatory means have been provided to the physicians. Both the implementers and target physicians considered the current lack of pain-related education as a hindrance to supporting the recommended behaviours.
We have used social and health psychological knowledge for conducting this intervention evaluation, but the results can also be discussed from the perspective of medical sociology. Occupational health care generally operates within biomedical paradigm. Biomedicine is often criticized for neglecting to give proper attention to the socio-cultural dynamics of pain care [44], and for failing to address the extent to which the pain sensation takes place as a product of interaction between neurophysiological processes, social contexts (e.g., working life) and cultural meaning [45,46,47]. Generally speaking, the OHS guidelines, aiming at better self-treatment of pain, reduction of medically certified absences, and improvement of physicians’ capability to deal with pain patients, can be viewed as an intention to de-medicalize pain care within a medical institution. The guidelines implementation can be represented as an interdisciplinary approach that intends to make the lived experience of human suffering an object of caring concern [46], providing social and psychological non-pharmacological tools for pain patients. Our results suggest that this type of approach with de-medicalization flavor may be effective but as the OHS pain patients were not under the scope of this study, we are not able to analyze how the changes in OHS were viewed among them.
The strength of this study is the use of descriptive quantitative data and qualitative data. Interviews with the OHS professionals allowed us to investigate possible factors influencing the observed sick leave trends. We used three different interview data sources, i.e., the implementers, target physicians and other OHS professionals, adding to the comprehensiveness of the data. Interviews with the implementers enabled us to characterize the OHS guidelines implementation intervention and to explore how it may have produced its effects. Implementers provided necessary information about the context and content of the intervention and allowed us to identify which of the outcomes, reported by the target physicians, could be attributed to the intervention and which to factors external to the intervention. For example, an e-learning course was a planned intervention means but rarely utilized by the target physicians. Instead, they reported gaining new knowledge from different sources outside the OHS. Implementers’ descriptions of the rationale behind the intervention allowed us to identify what physician behaviours they were trying to change, which barriers to the key behaviours they had identified and whether the barriers were targeted by theoretically appropriate intervention functions [26, 27]. It seems that key behaviours and their determinants had been explored and that there was theoretical coherence between identified barriers and means applied to address these barriers.
This is the first study, to our knowledge, to use the BCW and included COM-B model to evaluate a behaviour change intervention targeted to physicians in occupational health context. A theory-informed evaluation enabled us to explore how the intervention may have produced its effects. This examination also allowed the identification of current barriers to recommended practice which are not adequately addressed, suggesting needs for refinement of the ongoing intervention.
The COM-B model underlines the inter-connectedness of the three components [26]. Our data shows, for example, that occupational physicians used the printed guidelines check-lists with patients as recommended, when they had relevant knowledge and adequate time resources at the practice, but also believed that this behaviour benefits both patient and physician. On the other hand, some physicians were not aware of the check-lists (lacked knowledge), and the recommended behaviour did not occur despite adequate time resources and a motivation to serve the patients well. As for the general practitioners, they sometimes dismissed advising patients in time pressure even when they regarded this task as an important part of professional role and knew what to say to the patients.
The study has some limitations. Only approximately half of the invited OHS physicians volunteered to participate in the study. The appearance of COVID-19 pandemic increased physicians’ work strain and diminished willingness to contribute. It is difficult to recruit physicians for studies, and so this sample is quite good considering this hard-to-reach population. We collected an extensive amount of data on the topic and similar views and opinions started to appear during the course of the interviews (data saturation). The results may be biased to overestimate how the guidelines are implemented in the OHS. The interviewees may be likely to adhere to the guidelines more than others, or may represent a special subgroup of the staff with regard to some other issue. Thus, important barriers to guidelines-consistent behaviours may have been left unidentified in this study. However, participants varied with regard to their awareness of and ways of using the guidelines.
We had no data on physicians’ actual guidelines-related behaviours but relied on their self-assessments and descriptions of behaviours. In addition, the long intervention period is likely to affect the accuracy of memories of those who designed the intervention and those who have received it. Several intervention means may have been used but not recalled anymore during the interviews. We did not investigate factors influencing the delivery of the intervention itself. It is recommended that intervention evaluations start already during the launch of the intervention [19].
We identified specific behaviours (e.g. diagnosing and treating pain, assessing work disability) from the bundle of guidelines-related behaviours but enquired the interviewees’ perceptions of barriers and facilitators more generally. Influences of key behaviours may be different depending on the behaviour in question [6, 33, 38]. Furthermore, each of the key behaviours may consist of several sub-behaviours. A more fine-grained questioning would have required longer interviews but might have revealed relevant additional influences.
This study was conducted in Finland with a special occupational health care system. Industrialised countries differ considerably with regard to the content and coverage, organization and staffing of OHS [48]. Finnish occupational physicians have good possibilities to influence the number of sick leaves. In Finland, all employers must provide preventive occupational health care for their employees, and most employers also provide medical care at general practitioner level [49]. In 2015, OHS covered 84% of the employed workforce and 96% of wage earners in Finland, while, for example in Sweden, about 66% of the working force had access to OHS [49, 50]. In Sweden, occupational physicians prescribe small proportion of all sickness certificates, compared to occupational physicians, for example, in Finland and the Netherlands [50, 51].
Furthermore, the results come from a single OHS which, contrary to many corresponding Finnish organizations, serves only one client organization and has a unique revenue logic. Therefore, we are cautious to generalize the results to other contexts. Factors influencing physicians’ guidelines-related behaviours may be context-specific [6, 16]. However, we believe that the utilization of the BCW might be helpful in identifying barriers and facilitators of practice in a variety of jurisdictions and contexts. Further theory-informed research on the influences of behaviour is needed in other health care settings for more specific recommendations for intervention development.
