Factors related to work ability and well-being among women on sick leave due to long-term pain in the neck/shoulders and/or back: a cross-sectional study

Factors related to work ability and well-being among women on sick leave due to long-term pain in... Background: Musculoskeletal pain is one of the leading causes of sick leave, especially among women, in Western countries. The aim of the present study was to identify factors associated with work ability and well-being, respectively, among women on sick leave due to long-term pain in the neck/shoulders and/or back. Methods: A cross-sectional study with a correlational design was conducted on women who were sick-listed due to long-term pain in the neck/shoulders and/or back. A total of 208 participants responded to a survey comprising eight instruments: Multidimensional Pain Inventory scale, General Self-Efficacy scale, Sense of Coherence scale, Coping Strategies Questionnaire, Demand-Control-Support Questionnaire, Hospital Anxiety and Depression Scale, Work Ability Index and Life Satisfaction questionnaire. Multiple linear regression analyses were performed to identify factors associated with work ability and well-being, respectively. Results: Women who more strongly believed they would return to the same work had greater work ability (β = 0.39, p < 0.001), whereas women with higher pain intensity (β = − 0.30, p < 0.001) and higher job strain (β = − 0.12, p <0.05) had lower work ability. Women with higher self-efficacy rated greater well-being (β =0.14, p < 0.05). As the women’s scores for depression increased, their well-being decreased by 48%, which was statistically significant (p < 0.001). The regression models for work ability and well-being were significant (p < 0.001), and their adjusted R- square values were 48% and 59%, respectively. Conclusions: The study suggests that the factors beliefs to be back at the same work, pain intensity and job strain are predictive of work ability. Moreover, the factors self-efficacy and depression seem to be predictive of well-being. The findings highlight factors that should be considered by health care professionals and policy-makers to guide attempts to reduce sick leave. Keywords: Musculoskeletal pain, Sickness absence, Prognostic factors, Ability to work, Quality of life, Women Background leading causes of reduced work ability and well-being Sick leave due to long-term Musculoskeletal Pain (MSP) among workers [5]. Previous findings suggest that is considered an increasing public health problem in women have a higher prevalence of neck/shoulders and Western countries [1, 2]. The social economic costs of low back pain and are more likely to be on sick leave than sick leave are immense owing to workers’ compensation, men [2, 6, 7]. medical expenses and productivity loss [3, 4]. Long-term The concept of work ability comprises the physical, pain in the neck, shoulders and back is one of the psychological and social capability of a worker, which interact with the workers’ health condition, physical and * Correspondence: mamunur.rashid@hig.se mental resources and work demands [8, 9]. In this study, Centre for Musculoskeletal Research, Department of Occupational and work ability reflects the individual’s perceived current Public Health Sciences, Faculty of Health and Occupational Studies, University of Gävle, SE-80176 Gävle, Sweden and near future ability to perform work with respect to Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rashid et al. BMC Public Health (2018) 18:672 Page 2 of 8 work demands, health and mental resources [10]. In gen- Insurance Agency (SIA) to take part in the study. They eral, well-being reflects the meaningfulness of life with re- were selected on the basis of their medical certificate, is- gard to physical, mental and social dimensions [11], and sued by their primary health care or hospital physician. in this study, well-being is assessed through 10 dimensions Women were included in the study if they met the follow- of life satisfaction with regard to daily living using a ing criteria: 18 to 65 years of age; ≥ 50% sick leave from self-report checklist (LiSat- 11) [12]. Owing to the import- service (i.e., they could do part-time work); duration of ance of work ability and well-being in the working popula- sick leave ≥1 month due to pain in the neck/shoulders tion [2, 13–16], it is essential to understand which factors (ICD code: M53.1, M54.2, M54.9, M75.8, M75.9 and are important for work ability and well-being in this popu- M79.1) and/or back (ICD code: M54.4, M54.5, M54.9 and lation. Previous systematic reviews have attempted to M79.1) for ≥3 months. They should also be able to read, identify work-related and individual factors of importance write and understand Swedish. The exclusion criteria for work ability and well-being, but they have done so in were: rheumatoid arthritis, multiple sclerosis, stroke, the general working population or among people with cancer, Parkinson, bipolar disease, schizophrenia and MSP. For example, van den Berg et al. [17] found that pregnancy. An information letter and questionnaires were older age, obesity, poor musculoskeletal capacity, high sent to the women; two reminders were sent out. Of the mental work demands, poor physical work environment, 600 women, 275 responded to the questionnaires, giving a high physical work load, lack of autonomy and lack of response rate of 46%. Of them, 67 were excluded based on physical activity have a negative effect on work ability exclusion criteria, thus 208 were included in the analyses. among people with long-term MSP. Another review by Because the Swedish Social Insurance Agency invited Hoogendoorn et al. [18] presented strong evidence in- the women to take part in the study, the authors had dicating that low social support at work and low job no access to non-respondents’ data. For this reason, the satisfaction are related to reduced well-being among non-response analysis cannot be performed. back pain patients. It is possible that the factors of im- portance for work ability and well-being among people Data collection who are sick-listed are different owing to the severity of Self-administered questionnaires based on eight instruments their conditions [5, 8, 19, 20]. and a set of demographic variables such as age, educa- A recent systematic review showed that recovery beliefs, tion, country of birth, cohabitation, working conditions, health and work capacity were important for return to economic situation, physical activity and beliefs to be back work among people on sick leave due to long-term pain in at the same work were sent to the women. In addition, a the neck or back [16]. The authors concluded, however, pain figure was included to collect information on the that more studies were needed to confirm the results. Gen- location of pain on the body [27]. Subscales from six in- erating more knowledge about what is needed to improve struments were treated as independent variables and two work ability and well-being, and consequently to facilitate were used as outcome variables. A description of each return to work in this population would benefit individuals instrument is provided below. as well as society. However, previous studies have primarily focused on both women and men with sub-acute or Independent variables chronic pain who were working or on part-time sick leave Pain intensity [19–24]. As studies have shown that work tasks tend to dif- To assess pain intensity, the Multidimensional Pain Inven- fer between men and women, even in the same line of tory (MPI- S) [28] was used. The psychosocial section work [25, 26], it is possible that factors influencing work (part 1) consists of 28 items forming five sub-scales. In the ability also differs between genders. Therefore, they should present study, we analyzed only one sub-scale: pain inten- be investigated separately. Thus, the aim of the present sity, which consists of 3 items, where responses are made study was to identify factors associated with work ability on a 7-point Likert rating scale (0 = no pain; 6 = extreme and well-being, respectively, among women on sick leave pain), and where higher scores indicate higher pain inten- due to long-term pain in the neck/shoulders and/or back. sity. The internal consistency of the scale, measured using Cronbach’s α, was 0.76. Methods Study design The study was cross-sectional and used a correlational Self-efficacy design. To assess self-efficacy, the General Self-Efficacy (GSE) [29] scale was used. It consists of 10 items that respondents Sample rated on a 4-point Likert scale (1 = not true; 4 = completely In spring 2016, a total of 600 women from central and true). Total scores ranged from 10 to 40 points, higher northern Sweden were invited by the Swedish Social values indicating greater general self-efficacy. The internal Rashid et al. BMC Public Health (2018) 18:672 Page 3 of 8 consistency of the scale, measured using Cronbach’s α, on a 4-point Likert scale, where higher values indicate was 0.92. greater anxiety or depression. For each scale, a total score was calculated that ranged from 0 to 28 points. The in- Sense of coherence ternal consistency values for the scales, measured using Sense of coherence (SOC) is part of the salutogenic ap- Cronbach’s α, were 0.90 and 0.91, respectively. proach of health that focuses on one’s ability to identify re- Two additional factors were assessed using a single sources for health and well-being. SOC is the capability to item each. Beliefs to be back at the same work were manage whatever the situation demands in life to perceive assessed using the question: Do you believe you will re- life as comprehensible, manageable and meaningful [30]. turn to the same work within 6 months? These beliefs The SOC scale [30, 31], short version, was used to assess were assessed on a 10-point scale (from 1 = highly unlikely sense of coherence. The scale consists of 13 items, with to 10 = highly likely). Physical activity was assessed total scores ranging from 7 to 91 points. The respondents using the question: How often do you exercise regularly rated items on a 7-point scale (1 = never; 7 = very often), for at least 30 min, e.g., walking, jogging, swimming, cyc- where higher scores represent greater SOC. The internal ling or working in the garden? The four response alterna- consistency of the scale, measured using Cronbach’s α, tives were: 0 days/week, 1–3 days/week, 4–5 days/week, was 0.84. 6–7days/week. Coping strategies Outcome measures Coping strategies were assessed using the Swedish version Work ability of the Coping Strategies Questionnaire (CSQ) [32], which Work ability was assessed using the Work Ability Index consists of 50 individual items forming 8 sub-scales. In the (WAI) [10, 37], which consists of 7 items. For each item, present study, we used only three of the subscales: divert a single score was obtained, and the total WAI score was attention, ignore sensation, and increase behavioral activ- calculated by summing all single-item scores; the total ities. Each item was rated on a 7-point Likert scale ranging score ranged from 7 to 49 points. Lower scores indicate from 0 = never to 6 = always, higher values representing lower work ability. The internal consistency of the scale, more frequent use of the coping strategy. The internal measured using Cronbach’s α, was 0.78. consistency values for the sub-scales, measured using Cronbach’s α, were 0.87, 0.86 and 0.86, respectively. Well-being Well-being was measured using the Life Satisfaction Job strain and support at work questionnaire (LiSat- 11) [12, 38], which consists of 11 Job strain was assessed using the Demand Control Support items. Each item was rated on a 6-point ordinal scale Questionnaire (DCSQ) [33] which consists of 17 items ranging from 1 = very dissatisfied to 6 = very satisfied, where forming four subscales: psychosocial demands, skills dis- high scores reflect greater life satisfaction. The items were cretion, decision authority and support at work. For each averaged to produce the index of well-being. The internal item, responses were made on a 4-point Likert scale ran- consistency of the scale, measured using Cronbach’s α, ging from 1 (strongly agree) to 4 (strongly disagree). First, was 0.86. we constructed an index for each of the three scales: psy- chological demands, skills discretion and decision author- Potential confounders ity. Skills discretion and decision authority were then Age and economic situation were considered potential merged into one scale called decision latitude [34]. After- confounders in the analysis. They were chosen because wards, a job strain score was created by calculating the ra- they were found to be important confounders in a sys- tio between psychological demands and decision latitude, tematic review of factors important for return-to-work where higher values represent higher job strain [33]. For among people with long-term pain in neck or back [16]. the subscale support at work, the values for the six items Age was measured on a continuous scale, and economic were summed to a total score, where higher values repre- situation was assessed on a 5-point scale (from 1 = very sent greater perception of support at work. The internal dissatisfied to 5 = very satisfied). consistency of the scale, measured using Cronbach’s α,was 0.57 for job strain and 0.51 for support at work. Statistical analysis All data analyses were performed using the statistical Anxiety and depression software IBM SPSS, version 22. Descriptive statistics of Anxiety and depression were assessed using the Hospital demographic variables are presented as proportions, Anxiety and Depression Scale (HADS) [35, 36] which means and standard deviations. Scatterplots showed that consists of 14 items forming two scales: anxiety (7 items) all variables were normally distributed and that there and depression (7 items). Respondents rated each item were no outliers in the data. Prior to the regression Rashid et al. BMC Public Health (2018) 18:672 Page 4 of 8 analyses, multi-collinearity diagnostics using variance Table 1 Demographic characteristics of the participants (n =201–208) inflation factor (VIF) were applied, where all VIF values were less than 3.9, indicating no problem with multi- Variables Frequency (%) collinearity between independent variables in the models Age (years) (M, SD) 49.63 ± 9.71 [39]. Bivariate correlations between independent variables Country of birth were also computed [40]. To determine the association Sweden 200 (96) between the independent variables and work ability and Others 8 (4) well-being, respectively, multiple linear regression analyses Cohabitation were performed separately for each of the outcomes. The Living with partner 158 (76) analyses were performed with and without adjustment for age and economic situation, as data on 208 subjects gave Living alone 39 (19) sufficient statistical power to allow inclusion of all in- Living apart 11 (5) dependent variables and confounders in the models Education simultaneously. The level of significance was set at p < 0.05. Elementary 42 (20) Upper secondary 104 (50) Results University 53 (26) Table 1 describes the participants’ demographic charac- teristics. The mean age was around 50 years (range 23– Others 9 (4) 64 years). Ninety-six percent of the women were born in Types of work Sweden and 76% lived with a partner. Half of the women Blue-collar 145 (70) had upper secondary education, and 65% were satisfied White-collar 63 (30) with their economic situation. More than two-thirds of Working life prior to SL (years) (M, SD) 30.15 ± 10.75 the women (70%) had blue-collar work and 30% white- Economic situation collar. A total of 68% of the women experienced neck/ shoulder pain, 71% back pain, and 43% had pain in both Very dissatisfied 25 (12) areas. Dissatisfied 43 (21) Bivariate correlation coefficients between the independ- Acceptable 88 (42) ent variables were smaller than 0.55 (Table 2). Table 3 pre- Good 38 (18) sents the associations between the independent variables Very good 11 (5) and work ability. The results showed that women with Pain area higher pain intensity (β = - 0.30, p <0.001) and higher job strain (β = − 0.12, p < 0.05) had lower work ability, Neck/shoulders 142 (68) whereas women who believed more strongly that they Back 148 (71) would return to the same work within 6 months had Neck/shoulders and back 89 (43) greater work ability (β =0.39, p < 0.001). The regression Pain duration (months) (M, SD) 83.63 ± 99.64 model was significant (p < 0.001), and the independent Physical activity variables explained 48% of the variance in work 0 day/week 26 (13) ability. Table 4 shows that women with higher self-efficacy 1–3 days/week 81 (39) had greater well-being (β =0.14, p < 0.05). As the women’s 4–5 days/week 57 (27) scores for depression increased, their well-being decreased 6–7 days/week 41 (20) by 48% (β = − 0.48, p < 0.001). Economic situation per se Beliefs to be back at the same work (1–10 scale) (M, SD) 6.56 ± 3.73 was significantly related to well-being (β =0.14, p < 0 .05). Total working years before being sick-listed The regression model was significant (p < 0.001) and ex- M Mean and SD Standard deviation, SL Sick leave plained 59% of total the variation in well-being. Work ability Discussion In the present study, one of the important factors for The present findings revealed that women who more women’s work ability was pain intensity. Our finding strongly believed they would return to the same work had that higher pain intensity is associated with reduced greaterworkability,whereas womenwith higherpainin- work ability is not surprising and consistent with results tensity and higher job strain had lower work ability. from previous studies showing that increased MSP is in- Women with higher self-efficacy rated greater well-being, dependently associated with lower work ability in female and women’s well-being increased as their depression laboratory technicians as well as young and old workers decreased. [5, 13]. Other studies have found an impact of high Rashid et al. BMC Public Health (2018) 18:672 Page 5 of 8 Table 2 Bivariate Pearson’s correlation coefficients between independent variables included in the regression analyses (n = 196–208) Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1. Age 1 2. Economic situation 0.02 1 3. Pain intensity 0.14 0.07 1 4. Self-efficacy 0.01 0.03 0.23 1 5. Sense of coherence 0.09 0.01 0.32 − 0.06 1 6. Divert attention −0.06 − 0.02 − 0.12 0.30 0.41 1 7. Ignore sensation 0.01 −0.10 −0.04 0.01 0.15 0.23 1 a d d 8. IBA 0.02 − 0.10 0.11 0.04 0.01 0.43 0.54 1 9. Job strain 0.03 −0.01 −0.08 0.01 0.13 −0.13 −0.13 0.10 1 d d 10. Support at work −0.01 −0.06 −0.10 − 0.12 0.13 − 0.27 −0.37 − 0.01 −0.03 1 11. Physical activity −0.03 − 0.07 0.03 0.11 −0.07 0.01 0.01 0.04 −0.01 0.16 1 b c d d d d a d 12. BBSW −0.15 − 0.19 0.23 − 0.19 −0.40 0.11 −0.18 − 0.23 −0.06 − 0.02 −0.07 1 d a d d d d 13. Anxiety −0.02 0.04 −0.26 0.16 0.25 −0.47 −0.55 0.18 −0.01 0.07 0.14 0.32 1 d d d d 14. Depression −0.02 0.07 −0.32 0.13 0.35 −0.51 −0.13 − 0.12 −0.12 − 0.06 0.15 0.23 0.46 1 IBA Increase behavioral activities BBSW Beliefs to be back at the same work Correlation is significant at the 0.05 level Correlation is significant at the 0.01 level intensity of MSP including neck/shoulder and back, on due to pain in the neck/shoulders and/or back. The result low work ability among women and men [41, 42]. is in accordance with previous findings suggesting that We also found that high-job strain, i.e., high demands in high-job strain causes poor work ability [43]. Further, stud- combination with low decision latitude, was related to re- ies also found job strain to be an indicator of increased risk duced work ability among women on long-term sick leave of long-term sick leave and MSP intensity [44, 45]. Table 3 Multiple linear regression analyses between the independent variables and work ability Variables Work ability (n = 207) Unadjusted analysis Adjusted analysis β SE p-value β SE p-value Pain intensity − 0.32 0.46 0.001 −0.30 0.47 0.001 Self-efficacy 0.12 0.10 0.08 0.11 0.10 0.11 Sense of coherence −0.11 0.05 0.20 −0.10 0.05 0.31 Divert attention 0.04 0.10 0.52 0.02 0.11 0.78 Ignore sensation −0.11 0.09 0.11 −0.12 0.09 0.10 Increase behavioral activities 0.04 0.11 0.61 0.06 0.11 0.36 Job strain −0.12 2.15 0.04 − 0.12 2.16 0.04 Support at work 0.03 0.13 0.63 0.03 0.13 0.64 Physical activity −0.03 0.44 0.62 −0.04 0.45 0.55 Beliefs to be back at the same work 0.39 0.12 0.001 0.39 0.13 0.001 Anxiety −0.14 0.13 0.07 −0.13 0.13 0.08 Depression −0.15 0.15 0.07 −0.15 0.15 0.06 Age −0.09 0.04 0.13 Economic situation −0.04 0.45 0.63 R square 0.52 0.53 Adjusted R 0.49 0.48 β Standardized regression coefficient, SE Standard Error Note: Bold numbers represent significant values (p < 0.05) Rashid et al. BMC Public Health (2018) 18:672 Page 6 of 8 Table 4 Multiple linear regression analyses between the independent variables and well-being Variables Well-being (n = 168) Unadjusted analysis Adjusted analysis β SE p-value β SE p-value Pain intensity 0.05 0.55 0.45 0.06 0.57 0.36 Self-efficacy 0.16 0.12 0.02 0.14 0.12 0.03 Sense of coherence 0.17 0.06 0.04 0.14 0.06 0.09 Divert attention −0.09 0.12 0.19 −0.10 0.13 0.16 Ignore sensation −0.04 0.11 0.52 −0.02 0.11 0.82 Increase behavioral activities 0.02 0.13 0.80 −0.01 0.13 0.91 Job strain 0.08 2.60 0.17 0.08 2.58 0.15 Support at work −0.09 0.16 0.15 −0.09 0.16 0.17 Physical activity 0.03 0.53 0.60 0.03 0.53 0.65 Beliefs to be back at the same work 0.02 0.14 0.78 0.01 0.15 0.96 Anxiety −0.08 0.16 0.33 −0.08 0.16 0.30 Depression −0.49 0.18 0.001 −0.48 0.18 0.001 Age −0.03 0.05 0.57 Economic situation 0.14 0.54 0.02 R square 0.62 0.63 Adjusted R 0.59 0.59 β Standardized regression coefficient, SE Standard Error Note: Bold numbers represent significant values (p < 0.05) Our results also showed that women who believed an important coping factor among chronic pain patients they would return to the same work rated greater work [48, 49]. As expected, our study revealed an inverse as- ability. This is in line with a cross-sectional study dem- sociation between depression and well-being, suggesting onstrating that internal health-related control beliefs are that depression decreases well-being. This was not the an important individual resource that might moderate case for anxiety. Possibly, anxiety is obscured by the high the effect of work-related stressors on work ability [46]. prevalence of depression in this population [50]. A prospective cohort study also found recovery beliefs In our study, different factors were identified for work to be a predictor of return to work among male and fe- ability and well-being, respectively, meaning that different male workers with chronic low-back pain who were re- factors need to be targeted to achieve greater work ability ceiving sickness benefits [15]. as opposed to greater well-being. For example, the factors Contrary to our expectations, self-efficacy and sense of self-efficacy and depression were found to be significant coherence did not significantly contribute to work ability. for well-being, whereas these factors were not significantly This was surprising, as they have been found to be signifi- related to work ability. It should be noted, however, cant in previous studies among whiplash and chronic and that the factors were close to significant for work abil- sub-acute MSP patients [21, 22]. Similarly, factors such as ity. Previous studies have found self-efficacy and de- coping strategies, i.e., divert attention, ignore sensation pression to be important for work ability in patients and increase behavioral activities, and support at work did with chronic whiplash-associated disorder and for em- not appear to be significant in the present study, but have ployees on long-term sick leave [14, 21]. Our adjusted been found to be significant in previous studies for work analysis showed that the confounding factor, economic ability [19, 47]. One possible explanation is that the partic- situation, itself was significantly associated with well-being. ipants in our study were women on sick leave because If we regard economic situation as a personal factor, it is support at work is likely of more importance to people reasonable to assume when personal economy is good, it who are working. could provide access to other coping resources that support improved well-being [51–53]. Well-being The present study indicated that high self-efficacy was Strengths and limitations associated with increased well-being. The finding is sup- One of the strengths of the present study is the use of ported by previous studies suggesting that self-efficacy is validated scales to measure all independent variables and Rashid et al. BMC Public Health (2018) 18:672 Page 7 of 8 outcomes and use of well-defined inclusion criteria. The Acknowledgements The authors would like to extend their gratitude to all of the study participants selection of participants was based solely on what was spe- as well as to the Swedish Social Insurance Agency who assisted us in the data cified in the medical certificate issued by physician. Thus, collection. participants’ own opinions of their illness were not consid- Funding ered. Further, pain figure was used in order to check with This project was supported by University of Gävle (Reg. no. 2015/424). the information about pain in the neck/shoulders and/or back. In the invitation letter sent to the participants, it was Availability of data and materials The dataset underlying the present findings is available from the corresponding stressed that the project was made in collaboration be- author upon reasonable request. tween the SIA and the University of Gävle, and that non-response would not affect the women’s right to com- Authors’ contributions MR co-developed the study design, performed data collection, processing pensation. We believe that our results were not affected and analyses and drafted the manuscript. M-L K co-developed the study by SIA selecting participants. Two of the authors (MLK, design, performed data collection, and reviewed the initial drafts of the AN) instructed personnel at SIA in how to select partici- manuscript. MH co-developed the study design, contributed to the analyses, and reviewed the initial drafts of the manuscript. AN co-developed the study pants based on the inclusion and exclusion criteria. design, performed data collection, processing and analyses, and reviewed the The study has some limitations that should be noted. initial drafts of the manuscript. All authors have read and approved the final The number of non-response could raise questions about manuscript. potential selection bias. We believe there are two major Ethics approval and consent to participate reasons for the low response rate: (i) participation was This project was approved by the Regional Ethical Review Board, Uppsala, voluntary and no compensation was offered, and (ii) Sweden (Reg. no. 2.3.2–2015/548). A letter accompanying the questionnaire provided information about the study content and assured the confidentiality participants were unable to answer all the questions of the information. All participants provided their signed informed consent at due to pain. To increase the response rate, we sent two the time of data collection. consecutive reminders. As the study was cross-sectional Competing interests in design, inferences about cause and effect cannot be The authors declare that they have no competing interests. made. Longitudinal studies are required to confirm these results. Job strain and support at work, as mea- Publisher’sNote sured by the DCSQ, showed low internal consistency. Springer Nature remains neutral with regard to jurisdictional claims in Because work ability and well-being were measured published maps and institutional affiliations. using self-reported data, it is possible that the results Author details would have been different if objective measurements 1 Centre for Musculoskeletal Research, Department of Occupational and had been applied. Public Health Sciences, Faculty of Health and Occupational Studies, University of Gävle, SE-80176 Gävle, Sweden. Department of Health and Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden. Department of Public Health and Caring Sciences, Conclusion Faculty of Medicine, Uppsala University, Uppsala, Sweden. The present findings suggest that beliefs to be back at the Received: 10 November 2017 Accepted: 21 May 2018 same work, pain intensity and job strain are predictors of work ability, while self-efficacy and depression are predict- References ive of well-being among women on sick leave due to 1. Alexanderson K, Norlund A. Swedish council on technology assessment in long-term pain in neck/shoulders and/or back. Hence, the health care (SBU). Chapter 1. Aim, background, key concepts, regulations, present study showed that the factors associated with and current statistics. Scandinavian journal of public health. Supplement. England. 2004;63:12–30. work ability were not the same as those associated with 2. 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Factors related to work ability and well-being among women on sick leave due to long-term pain in the neck/shoulders and/or back: a cross-sectional study

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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: Musculoskeletal pain is one of the leading causes of sick leave, especially among women, in Western countries. The aim of the present study was to identify factors associated with work ability and well-being, respectively, among women on sick leave due to long-term pain in the neck/shoulders and/or back. Methods: A cross-sectional study with a correlational design was conducted on women who were sick-listed due to long-term pain in the neck/shoulders and/or back. A total of 208 participants responded to a survey comprising eight instruments: Multidimensional Pain Inventory scale, General Self-Efficacy scale, Sense of Coherence scale, Coping Strategies Questionnaire, Demand-Control-Support Questionnaire, Hospital Anxiety and Depression Scale, Work Ability Index and Life Satisfaction questionnaire. Multiple linear regression analyses were performed to identify factors associated with work ability and well-being, respectively. Results: Women who more strongly believed they would return to the same work had greater work ability (β = 0.39, p < 0.001), whereas women with higher pain intensity (β = − 0.30, p < 0.001) and higher job strain (β = − 0.12, p <0.05) had lower work ability. Women with higher self-efficacy rated greater well-being (β =0.14, p < 0.05). As the women’s scores for depression increased, their well-being decreased by 48%, which was statistically significant (p < 0.001). The regression models for work ability and well-being were significant (p < 0.001), and their adjusted R- square values were 48% and 59%, respectively. Conclusions: The study suggests that the factors beliefs to be back at the same work, pain intensity and job strain are predictive of work ability. Moreover, the factors self-efficacy and depression seem to be predictive of well-being. The findings highlight factors that should be considered by health care professionals and policy-makers to guide attempts to reduce sick leave. Keywords: Musculoskeletal pain, Sickness absence, Prognostic factors, Ability to work, Quality of life, Women Background leading causes of reduced work ability and well-being Sick leave due to long-term Musculoskeletal Pain (MSP) among workers [5]. Previous findings suggest that is considered an increasing public health problem in women have a higher prevalence of neck/shoulders and Western countries [1, 2]. The social economic costs of low back pain and are more likely to be on sick leave than sick leave are immense owing to workers’ compensation, men [2, 6, 7]. medical expenses and productivity loss [3, 4]. Long-term The concept of work ability comprises the physical, pain in the neck, shoulders and back is one of the psychological and social capability of a worker, which interact with the workers’ health condition, physical and * Correspondence: mamunur.rashid@hig.se mental resources and work demands [8, 9]. In this study, Centre for Musculoskeletal Research, Department of Occupational and work ability reflects the individual’s perceived current Public Health Sciences, Faculty of Health and Occupational Studies, University of Gävle, SE-80176 Gävle, Sweden and near future ability to perform work with respect to Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rashid et al. BMC Public Health (2018) 18:672 Page 2 of 8 work demands, health and mental resources [10]. In gen- Insurance Agency (SIA) to take part in the study. They eral, well-being reflects the meaningfulness of life with re- were selected on the basis of their medical certificate, is- gard to physical, mental and social dimensions [11], and sued by their primary health care or hospital physician. in this study, well-being is assessed through 10 dimensions Women were included in the study if they met the follow- of life satisfaction with regard to daily living using a ing criteria: 18 to 65 years of age; ≥ 50% sick leave from self-report checklist (LiSat- 11) [12]. Owing to the import- service (i.e., they could do part-time work); duration of ance of work ability and well-being in the working popula- sick leave ≥1 month due to pain in the neck/shoulders tion [2, 13–16], it is essential to understand which factors (ICD code: M53.1, M54.2, M54.9, M75.8, M75.9 and are important for work ability and well-being in this popu- M79.1) and/or back (ICD code: M54.4, M54.5, M54.9 and lation. Previous systematic reviews have attempted to M79.1) for ≥3 months. They should also be able to read, identify work-related and individual factors of importance write and understand Swedish. The exclusion criteria for work ability and well-being, but they have done so in were: rheumatoid arthritis, multiple sclerosis, stroke, the general working population or among people with cancer, Parkinson, bipolar disease, schizophrenia and MSP. For example, van den Berg et al. [17] found that pregnancy. An information letter and questionnaires were older age, obesity, poor musculoskeletal capacity, high sent to the women; two reminders were sent out. Of the mental work demands, poor physical work environment, 600 women, 275 responded to the questionnaires, giving a high physical work load, lack of autonomy and lack of response rate of 46%. Of them, 67 were excluded based on physical activity have a negative effect on work ability exclusion criteria, thus 208 were included in the analyses. among people with long-term MSP. Another review by Because the Swedish Social Insurance Agency invited Hoogendoorn et al. [18] presented strong evidence in- the women to take part in the study, the authors had dicating that low social support at work and low job no access to non-respondents’ data. For this reason, the satisfaction are related to reduced well-being among non-response analysis cannot be performed. back pain patients. It is possible that the factors of im- portance for work ability and well-being among people Data collection who are sick-listed are different owing to the severity of Self-administered questionnaires based on eight instruments their conditions [5, 8, 19, 20]. and a set of demographic variables such as age, educa- A recent systematic review showed that recovery beliefs, tion, country of birth, cohabitation, working conditions, health and work capacity were important for return to economic situation, physical activity and beliefs to be back work among people on sick leave due to long-term pain in at the same work were sent to the women. In addition, a the neck or back [16]. The authors concluded, however, pain figure was included to collect information on the that more studies were needed to confirm the results. Gen- location of pain on the body [27]. Subscales from six in- erating more knowledge about what is needed to improve struments were treated as independent variables and two work ability and well-being, and consequently to facilitate were used as outcome variables. A description of each return to work in this population would benefit individuals instrument is provided below. as well as society. However, previous studies have primarily focused on both women and men with sub-acute or Independent variables chronic pain who were working or on part-time sick leave Pain intensity [19–24]. As studies have shown that work tasks tend to dif- To assess pain intensity, the Multidimensional Pain Inven- fer between men and women, even in the same line of tory (MPI- S) [28] was used. The psychosocial section work [25, 26], it is possible that factors influencing work (part 1) consists of 28 items forming five sub-scales. In the ability also differs between genders. Therefore, they should present study, we analyzed only one sub-scale: pain inten- be investigated separately. Thus, the aim of the present sity, which consists of 3 items, where responses are made study was to identify factors associated with work ability on a 7-point Likert rating scale (0 = no pain; 6 = extreme and well-being, respectively, among women on sick leave pain), and where higher scores indicate higher pain inten- due to long-term pain in the neck/shoulders and/or back. sity. The internal consistency of the scale, measured using Cronbach’s α, was 0.76. Methods Study design The study was cross-sectional and used a correlational Self-efficacy design. To assess self-efficacy, the General Self-Efficacy (GSE) [29] scale was used. It consists of 10 items that respondents Sample rated on a 4-point Likert scale (1 = not true; 4 = completely In spring 2016, a total of 600 women from central and true). Total scores ranged from 10 to 40 points, higher northern Sweden were invited by the Swedish Social values indicating greater general self-efficacy. The internal Rashid et al. BMC Public Health (2018) 18:672 Page 3 of 8 consistency of the scale, measured using Cronbach’s α, on a 4-point Likert scale, where higher values indicate was 0.92. greater anxiety or depression. For each scale, a total score was calculated that ranged from 0 to 28 points. The in- Sense of coherence ternal consistency values for the scales, measured using Sense of coherence (SOC) is part of the salutogenic ap- Cronbach’s α, were 0.90 and 0.91, respectively. proach of health that focuses on one’s ability to identify re- Two additional factors were assessed using a single sources for health and well-being. SOC is the capability to item each. Beliefs to be back at the same work were manage whatever the situation demands in life to perceive assessed using the question: Do you believe you will re- life as comprehensible, manageable and meaningful [30]. turn to the same work within 6 months? These beliefs The SOC scale [30, 31], short version, was used to assess were assessed on a 10-point scale (from 1 = highly unlikely sense of coherence. The scale consists of 13 items, with to 10 = highly likely). Physical activity was assessed total scores ranging from 7 to 91 points. The respondents using the question: How often do you exercise regularly rated items on a 7-point scale (1 = never; 7 = very often), for at least 30 min, e.g., walking, jogging, swimming, cyc- where higher scores represent greater SOC. The internal ling or working in the garden? The four response alterna- consistency of the scale, measured using Cronbach’s α, tives were: 0 days/week, 1–3 days/week, 4–5 days/week, was 0.84. 6–7days/week. Coping strategies Outcome measures Coping strategies were assessed using the Swedish version Work ability of the Coping Strategies Questionnaire (CSQ) [32], which Work ability was assessed using the Work Ability Index consists of 50 individual items forming 8 sub-scales. In the (WAI) [10, 37], which consists of 7 items. For each item, present study, we used only three of the subscales: divert a single score was obtained, and the total WAI score was attention, ignore sensation, and increase behavioral activ- calculated by summing all single-item scores; the total ities. Each item was rated on a 7-point Likert scale ranging score ranged from 7 to 49 points. Lower scores indicate from 0 = never to 6 = always, higher values representing lower work ability. The internal consistency of the scale, more frequent use of the coping strategy. The internal measured using Cronbach’s α, was 0.78. consistency values for the sub-scales, measured using Cronbach’s α, were 0.87, 0.86 and 0.86, respectively. Well-being Well-being was measured using the Life Satisfaction Job strain and support at work questionnaire (LiSat- 11) [12, 38], which consists of 11 Job strain was assessed using the Demand Control Support items. Each item was rated on a 6-point ordinal scale Questionnaire (DCSQ) [33] which consists of 17 items ranging from 1 = very dissatisfied to 6 = very satisfied, where forming four subscales: psychosocial demands, skills dis- high scores reflect greater life satisfaction. The items were cretion, decision authority and support at work. For each averaged to produce the index of well-being. The internal item, responses were made on a 4-point Likert scale ran- consistency of the scale, measured using Cronbach’s α, ging from 1 (strongly agree) to 4 (strongly disagree). First, was 0.86. we constructed an index for each of the three scales: psy- chological demands, skills discretion and decision author- Potential confounders ity. Skills discretion and decision authority were then Age and economic situation were considered potential merged into one scale called decision latitude [34]. After- confounders in the analysis. They were chosen because wards, a job strain score was created by calculating the ra- they were found to be important confounders in a sys- tio between psychological demands and decision latitude, tematic review of factors important for return-to-work where higher values represent higher job strain [33]. For among people with long-term pain in neck or back [16]. the subscale support at work, the values for the six items Age was measured on a continuous scale, and economic were summed to a total score, where higher values repre- situation was assessed on a 5-point scale (from 1 = very sent greater perception of support at work. The internal dissatisfied to 5 = very satisfied). consistency of the scale, measured using Cronbach’s α,was 0.57 for job strain and 0.51 for support at work. Statistical analysis All data analyses were performed using the statistical Anxiety and depression software IBM SPSS, version 22. Descriptive statistics of Anxiety and depression were assessed using the Hospital demographic variables are presented as proportions, Anxiety and Depression Scale (HADS) [35, 36] which means and standard deviations. Scatterplots showed that consists of 14 items forming two scales: anxiety (7 items) all variables were normally distributed and that there and depression (7 items). Respondents rated each item were no outliers in the data. Prior to the regression Rashid et al. BMC Public Health (2018) 18:672 Page 4 of 8 analyses, multi-collinearity diagnostics using variance Table 1 Demographic characteristics of the participants (n =201–208) inflation factor (VIF) were applied, where all VIF values were less than 3.9, indicating no problem with multi- Variables Frequency (%) collinearity between independent variables in the models Age (years) (M, SD) 49.63 ± 9.71 [39]. Bivariate correlations between independent variables Country of birth were also computed [40]. To determine the association Sweden 200 (96) between the independent variables and work ability and Others 8 (4) well-being, respectively, multiple linear regression analyses Cohabitation were performed separately for each of the outcomes. The Living with partner 158 (76) analyses were performed with and without adjustment for age and economic situation, as data on 208 subjects gave Living alone 39 (19) sufficient statistical power to allow inclusion of all in- Living apart 11 (5) dependent variables and confounders in the models Education simultaneously. The level of significance was set at p < 0.05. Elementary 42 (20) Upper secondary 104 (50) Results University 53 (26) Table 1 describes the participants’ demographic charac- teristics. The mean age was around 50 years (range 23– Others 9 (4) 64 years). Ninety-six percent of the women were born in Types of work Sweden and 76% lived with a partner. Half of the women Blue-collar 145 (70) had upper secondary education, and 65% were satisfied White-collar 63 (30) with their economic situation. More than two-thirds of Working life prior to SL (years) (M, SD) 30.15 ± 10.75 the women (70%) had blue-collar work and 30% white- Economic situation collar. A total of 68% of the women experienced neck/ shoulder pain, 71% back pain, and 43% had pain in both Very dissatisfied 25 (12) areas. Dissatisfied 43 (21) Bivariate correlation coefficients between the independ- Acceptable 88 (42) ent variables were smaller than 0.55 (Table 2). Table 3 pre- Good 38 (18) sents the associations between the independent variables Very good 11 (5) and work ability. The results showed that women with Pain area higher pain intensity (β = - 0.30, p <0.001) and higher job strain (β = − 0.12, p < 0.05) had lower work ability, Neck/shoulders 142 (68) whereas women who believed more strongly that they Back 148 (71) would return to the same work within 6 months had Neck/shoulders and back 89 (43) greater work ability (β =0.39, p < 0.001). The regression Pain duration (months) (M, SD) 83.63 ± 99.64 model was significant (p < 0.001), and the independent Physical activity variables explained 48% of the variance in work 0 day/week 26 (13) ability. Table 4 shows that women with higher self-efficacy 1–3 days/week 81 (39) had greater well-being (β =0.14, p < 0.05). As the women’s 4–5 days/week 57 (27) scores for depression increased, their well-being decreased 6–7 days/week 41 (20) by 48% (β = − 0.48, p < 0.001). Economic situation per se Beliefs to be back at the same work (1–10 scale) (M, SD) 6.56 ± 3.73 was significantly related to well-being (β =0.14, p < 0 .05). Total working years before being sick-listed The regression model was significant (p < 0.001) and ex- M Mean and SD Standard deviation, SL Sick leave plained 59% of total the variation in well-being. Work ability Discussion In the present study, one of the important factors for The present findings revealed that women who more women’s work ability was pain intensity. Our finding strongly believed they would return to the same work had that higher pain intensity is associated with reduced greaterworkability,whereas womenwith higherpainin- work ability is not surprising and consistent with results tensity and higher job strain had lower work ability. from previous studies showing that increased MSP is in- Women with higher self-efficacy rated greater well-being, dependently associated with lower work ability in female and women’s well-being increased as their depression laboratory technicians as well as young and old workers decreased. [5, 13]. Other studies have found an impact of high Rashid et al. BMC Public Health (2018) 18:672 Page 5 of 8 Table 2 Bivariate Pearson’s correlation coefficients between independent variables included in the regression analyses (n = 196–208) Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1. Age 1 2. Economic situation 0.02 1 3. Pain intensity 0.14 0.07 1 4. Self-efficacy 0.01 0.03 0.23 1 5. Sense of coherence 0.09 0.01 0.32 − 0.06 1 6. Divert attention −0.06 − 0.02 − 0.12 0.30 0.41 1 7. Ignore sensation 0.01 −0.10 −0.04 0.01 0.15 0.23 1 a d d 8. IBA 0.02 − 0.10 0.11 0.04 0.01 0.43 0.54 1 9. Job strain 0.03 −0.01 −0.08 0.01 0.13 −0.13 −0.13 0.10 1 d d 10. Support at work −0.01 −0.06 −0.10 − 0.12 0.13 − 0.27 −0.37 − 0.01 −0.03 1 11. Physical activity −0.03 − 0.07 0.03 0.11 −0.07 0.01 0.01 0.04 −0.01 0.16 1 b c d d d d a d 12. BBSW −0.15 − 0.19 0.23 − 0.19 −0.40 0.11 −0.18 − 0.23 −0.06 − 0.02 −0.07 1 d a d d d d 13. Anxiety −0.02 0.04 −0.26 0.16 0.25 −0.47 −0.55 0.18 −0.01 0.07 0.14 0.32 1 d d d d 14. Depression −0.02 0.07 −0.32 0.13 0.35 −0.51 −0.13 − 0.12 −0.12 − 0.06 0.15 0.23 0.46 1 IBA Increase behavioral activities BBSW Beliefs to be back at the same work Correlation is significant at the 0.05 level Correlation is significant at the 0.01 level intensity of MSP including neck/shoulder and back, on due to pain in the neck/shoulders and/or back. The result low work ability among women and men [41, 42]. is in accordance with previous findings suggesting that We also found that high-job strain, i.e., high demands in high-job strain causes poor work ability [43]. Further, stud- combination with low decision latitude, was related to re- ies also found job strain to be an indicator of increased risk duced work ability among women on long-term sick leave of long-term sick leave and MSP intensity [44, 45]. Table 3 Multiple linear regression analyses between the independent variables and work ability Variables Work ability (n = 207) Unadjusted analysis Adjusted analysis β SE p-value β SE p-value Pain intensity − 0.32 0.46 0.001 −0.30 0.47 0.001 Self-efficacy 0.12 0.10 0.08 0.11 0.10 0.11 Sense of coherence −0.11 0.05 0.20 −0.10 0.05 0.31 Divert attention 0.04 0.10 0.52 0.02 0.11 0.78 Ignore sensation −0.11 0.09 0.11 −0.12 0.09 0.10 Increase behavioral activities 0.04 0.11 0.61 0.06 0.11 0.36 Job strain −0.12 2.15 0.04 − 0.12 2.16 0.04 Support at work 0.03 0.13 0.63 0.03 0.13 0.64 Physical activity −0.03 0.44 0.62 −0.04 0.45 0.55 Beliefs to be back at the same work 0.39 0.12 0.001 0.39 0.13 0.001 Anxiety −0.14 0.13 0.07 −0.13 0.13 0.08 Depression −0.15 0.15 0.07 −0.15 0.15 0.06 Age −0.09 0.04 0.13 Economic situation −0.04 0.45 0.63 R square 0.52 0.53 Adjusted R 0.49 0.48 β Standardized regression coefficient, SE Standard Error Note: Bold numbers represent significant values (p < 0.05) Rashid et al. BMC Public Health (2018) 18:672 Page 6 of 8 Table 4 Multiple linear regression analyses between the independent variables and well-being Variables Well-being (n = 168) Unadjusted analysis Adjusted analysis β SE p-value β SE p-value Pain intensity 0.05 0.55 0.45 0.06 0.57 0.36 Self-efficacy 0.16 0.12 0.02 0.14 0.12 0.03 Sense of coherence 0.17 0.06 0.04 0.14 0.06 0.09 Divert attention −0.09 0.12 0.19 −0.10 0.13 0.16 Ignore sensation −0.04 0.11 0.52 −0.02 0.11 0.82 Increase behavioral activities 0.02 0.13 0.80 −0.01 0.13 0.91 Job strain 0.08 2.60 0.17 0.08 2.58 0.15 Support at work −0.09 0.16 0.15 −0.09 0.16 0.17 Physical activity 0.03 0.53 0.60 0.03 0.53 0.65 Beliefs to be back at the same work 0.02 0.14 0.78 0.01 0.15 0.96 Anxiety −0.08 0.16 0.33 −0.08 0.16 0.30 Depression −0.49 0.18 0.001 −0.48 0.18 0.001 Age −0.03 0.05 0.57 Economic situation 0.14 0.54 0.02 R square 0.62 0.63 Adjusted R 0.59 0.59 β Standardized regression coefficient, SE Standard Error Note: Bold numbers represent significant values (p < 0.05) Our results also showed that women who believed an important coping factor among chronic pain patients they would return to the same work rated greater work [48, 49]. As expected, our study revealed an inverse as- ability. This is in line with a cross-sectional study dem- sociation between depression and well-being, suggesting onstrating that internal health-related control beliefs are that depression decreases well-being. This was not the an important individual resource that might moderate case for anxiety. Possibly, anxiety is obscured by the high the effect of work-related stressors on work ability [46]. prevalence of depression in this population [50]. A prospective cohort study also found recovery beliefs In our study, different factors were identified for work to be a predictor of return to work among male and fe- ability and well-being, respectively, meaning that different male workers with chronic low-back pain who were re- factors need to be targeted to achieve greater work ability ceiving sickness benefits [15]. as opposed to greater well-being. For example, the factors Contrary to our expectations, self-efficacy and sense of self-efficacy and depression were found to be significant coherence did not significantly contribute to work ability. for well-being, whereas these factors were not significantly This was surprising, as they have been found to be signifi- related to work ability. It should be noted, however, cant in previous studies among whiplash and chronic and that the factors were close to significant for work abil- sub-acute MSP patients [21, 22]. Similarly, factors such as ity. Previous studies have found self-efficacy and de- coping strategies, i.e., divert attention, ignore sensation pression to be important for work ability in patients and increase behavioral activities, and support at work did with chronic whiplash-associated disorder and for em- not appear to be significant in the present study, but have ployees on long-term sick leave [14, 21]. Our adjusted been found to be significant in previous studies for work analysis showed that the confounding factor, economic ability [19, 47]. One possible explanation is that the partic- situation, itself was significantly associated with well-being. ipants in our study were women on sick leave because If we regard economic situation as a personal factor, it is support at work is likely of more importance to people reasonable to assume when personal economy is good, it who are working. could provide access to other coping resources that support improved well-being [51–53]. Well-being The present study indicated that high self-efficacy was Strengths and limitations associated with increased well-being. The finding is sup- One of the strengths of the present study is the use of ported by previous studies suggesting that self-efficacy is validated scales to measure all independent variables and Rashid et al. BMC Public Health (2018) 18:672 Page 7 of 8 outcomes and use of well-defined inclusion criteria. The Acknowledgements The authors would like to extend their gratitude to all of the study participants selection of participants was based solely on what was spe- as well as to the Swedish Social Insurance Agency who assisted us in the data cified in the medical certificate issued by physician. Thus, collection. participants’ own opinions of their illness were not consid- Funding ered. Further, pain figure was used in order to check with This project was supported by University of Gävle (Reg. no. 2015/424). the information about pain in the neck/shoulders and/or back. In the invitation letter sent to the participants, it was Availability of data and materials The dataset underlying the present findings is available from the corresponding stressed that the project was made in collaboration be- author upon reasonable request. tween the SIA and the University of Gävle, and that non-response would not affect the women’s right to com- Authors’ contributions MR co-developed the study design, performed data collection, processing pensation. We believe that our results were not affected and analyses and drafted the manuscript. M-L K co-developed the study by SIA selecting participants. Two of the authors (MLK, design, performed data collection, and reviewed the initial drafts of the AN) instructed personnel at SIA in how to select partici- manuscript. MH co-developed the study design, contributed to the analyses, and reviewed the initial drafts of the manuscript. AN co-developed the study pants based on the inclusion and exclusion criteria. design, performed data collection, processing and analyses, and reviewed the The study has some limitations that should be noted. initial drafts of the manuscript. All authors have read and approved the final The number of non-response could raise questions about manuscript. potential selection bias. We believe there are two major Ethics approval and consent to participate reasons for the low response rate: (i) participation was This project was approved by the Regional Ethical Review Board, Uppsala, voluntary and no compensation was offered, and (ii) Sweden (Reg. no. 2.3.2–2015/548). A letter accompanying the questionnaire provided information about the study content and assured the confidentiality participants were unable to answer all the questions of the information. All participants provided their signed informed consent at due to pain. To increase the response rate, we sent two the time of data collection. consecutive reminders. As the study was cross-sectional Competing interests in design, inferences about cause and effect cannot be The authors declare that they have no competing interests. made. Longitudinal studies are required to confirm these results. Job strain and support at work, as mea- Publisher’sNote sured by the DCSQ, showed low internal consistency. Springer Nature remains neutral with regard to jurisdictional claims in Because work ability and well-being were measured published maps and institutional affiliations. using self-reported data, it is possible that the results Author details would have been different if objective measurements 1 Centre for Musculoskeletal Research, Department of Occupational and had been applied. Public Health Sciences, Faculty of Health and Occupational Studies, University of Gävle, SE-80176 Gävle, Sweden. 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