Barriers and Facilitators for Implementing Motivational Interviewing as a Return to Work Intervention in a Norwegian Social Insurance Setting: A Mixed Methods Process Evaluation

Getting an outsider's perspective - sick-listed workers' experiences with early follow-up sessions in the return to work process: a qualitative interview study

PURPOSE

The aim of this study was to explore how early follow-up sessions (after 14 and 16 weeks of sick leave) with social insurance caseworkers was experienced by sick-listed workers, and how these sessions influenced their return-to-work process.

METHODS

A qualitative interview study with sick-listed workers who completed two early follow-up sessions with caseworkers from the Norwegian Labor and Welfare Administration (NAV). Twenty-six individuals aged 30 to 60 years with a sick leave status of 50-100% participated in semi-structured interviews. The data was analyzed with thematic analysis.

RESULTS

Participants' experiences of the early follow-up sessions could be categorized into three themes: (1) Getting an outsider's perspective, (2) enhanced understanding of the framework for long term sick-leave, and (3) the empathic and personal face of the social insurance system. Meeting a caseworker enabled an outsider perspective that promoted critical reflection and calibration of their thoughts. This was experienced as a useful addition to the support many received from their informal network, such as friends, family, and co-workers. The meetings also enabled a greater understanding of their rights and duties, possibilities, and limitations regarding welfare benefits, while also displaying an unexpected empathic and understanding perspective from those working in the social insurance system.

CONCLUSION

For sick-listed individuals, receiving an early follow-up session from social insurance caseworkers was a positive experience that enhanced their understanding of their situation, and promoted reflection towards RTW. Thus, from the perspective of the sick-listed workers, early sessions with social insurance caseworkers could be a useful addition to the overall sickness absence follow-up.

Developing a Training in Motivational Counselling to Promote Return to Work: An Intervention Mapping Approach

PURPOSE

Due to the Belgian health insurance system's controlling nature, work-disabled claimants can feel forced to return to work (RTW), increasing their risk of relapse. RTW out of interest or importance is considered more sustainable. Such autonomous motivation for RTW can be promoted through 'motivational counselling', an integration of self-determination theory and motivational interviewing. To adopt this, health insurance practitioners need training, which can be designed through intervention mapping as an evidence-based planning tool. This paper reports on the development of a motivational counselling training for health insurance practitioners.

METHODS

Intervention mapping's six steps guided the formulation of programme goals and learning outcomes, matching the context. We then identified change methods which were translated into practical components. Together with the health insurances' input, this resulted in a concrete training programme with an implementation and evaluation plan.

RESULTS

The training was designed to increase practitioners' knowledge, skills, and beliefs relevant for learning motivational counselling, which also requires solution-focused strategies. Methods like guided practice were translated into built-in exercises, feedback, and information, which were implemented through an online training format of five sessions including one follow-up.

CONCLUSION

Reporting about training development increases understanding of its effectiveness and implementation, which will be evaluated via pre- and post-training data collection amongst practitioners. Future trainings can benefit from this by accounting for health insurances' organizational barriers or building on the training's evidence-based backbone whilst only requiring specific adaptations for other stakeholders and contexts. Further research should evaluate motivational counselling's impact on claimants' RTW trajectories.

Effectiveness of 'motivational interviewing' on sick leave: a randomized controlled trial in a social insurance setting

OBJECTIVE

This study aimed to evaluate the effectiveness of motivational interviewing (MI) - a counselling approach offered by caseworkers at the Norwegian Labor and Welfare Administration (NAV) - on return to work (RTW) for individuals sick-listed for ≥8 weeks due to any diagnoses. MI was compared to usual case management and an active control during 12 months of follow-up.

METHODS

In a randomized clinical trial with three parallel arms, participants were randomized to MI (N=257), usual case management (N=266), or an active control group (N=252). MI consisted of two MI sessions while the active control involved two sessions without MI, both were offered in addition to usual case management. The primary outcome was number of sickness absence days based on registry data. Secondary outcomes included time to sustainable RTW, defined as four consecutive weeks without medical benefits.

RESULTS

The median number of sickness absence days for the MI group was 73 days [interquartile range (IQR) 31-147], 76 days (35-134) for usual care, and 75 days (34-155) for active control. In total 89%, 88% and 86% of the participants, respectively, achieved sustainable RTW. The adjusted hazard ratio (HR) for time to sustainable RTW was 1.12 (95% CI 0.90-1.40) for MI compared to usual case management and HR 1.16 (95% CI 0.93-1.44) compared to the active control.

CONCLUSIONS

This study did not provide evidence that MI offered by NAV caseworkers to sick-listed individuals was more effective on RTW than usual case management or an active control. Providing MI in this context could be challenging as only half of the MI group received the intervention.

Fidelity of a Motivational Interviewing Intervention for Improving Return to Work for People with Musculoskeletal Disorders

The objective of this study was to conduct a fidelity evaluation of a motivational interviewing (MI) intervention delivered by social insurance caseworkers, in a three-arm randomized controlled trial (RCT) for improving return to work for people on sick leave with musculoskeletal disorders. The caseworkers received six days of MI training, including an intervention manual prior to the trial onset, as well as supervision throughout the trial. The caseworkers recorded 21 MI sessions at regular intervals during the trial. An independent MI analysis center scored the recordings using the MI treatment integrity code (MITI 4). In addition, three experienced MI trainers assessed the adherence to the MI intervention manual on a 1–4 Likert scale and MI competence. Total MITI 4 mean scores were at beginning proficiency levels for two components (global technical, mean 3.0; SD 0.6 and the reflections/questions ratio, mean 1.1; SD 0.2) and under beginning proficiency for two components (global relational, mean 3.2; SD 0.7 and complex question, mean 34.0; SD 21.2). The MI trainers’ assessment showed similar results. The mean adherence score for the MI sessions was 2.96 (SD 0.9). Despite delivering a thorough course and supervision package, most of the caseworkers did not reach proficiency levels of good MI competence during the study. The fidelity evaluation showed that a large amount of training, supervision and practice is needed for caseworkers to become competent MI providers. When planning to implement MI, it is important that thorough consideration is given regarding the resources and the time needed to train caseworkers to provide MI in a social insurance setting.