Return-to-work for unemployed people with persistent pain

Adapting and piloting a cohort randomised approach, and exploring obstacles and facilitators using in-depth interviews

Abstract

Background: Persistent pain is a frequent cause of work disability and welfare benefit payments, posing substantial challenges to the Norwegian welfare system. The return-to-work process for individuals experiencing persistent pain is multifaceted, with limited understanding of the obstacles and facilitators faced by those receiving welfare benefits. An intervention, developed in the UK, targeted unemployed individuals suffering from persistent pain and actively involved them in identifying their individual obstacles to work within a biopsychosocial framework in addition to providing a supported placement. This approach demonstrated a promising 20% return-to-work rate within six-months of follow-up in the UK context. However, it remains uncertain whether this intervention is feasible in the Norwegian context and yield similar results. Aims: 1) To culturally adapt the UK intervention for delivery in Norway, and conduct a national pilot study using a cohort randomised approach; 2) to confirm the feasibility of the adapted intervention prior to conducting a full-scale trial; and 3) to explore the obstacles and facilitators for participants with persistent pain attempting to return-to-work while receiving benefits. Methods: In Paper I, the UK intervention materials were culturally adapted for the Norwegian context through a process that included forward- and back-translation, review and consensus, comprehension testing, and re-designing. A survey was conducted to evaluate the quality, value, acceptability, and clarity of the adapted materials among end-users. In Paper II, a pragmatic cohort randomised controlled approach was used to pilot the adapted intervention. People who were unemployed, who had persistent pain, who were aged between 18 and 64, and who wanted to work, were recruited to an observational cohort study. After baseline measurement, participants were randomly sub-sampled to be offered the intervention, which included individual case management and support, work-familiarisation sessions, and the offer of a six-week part-time work placement. The study assessed recruitment rates and pathways, intervention acceptance rates, data collection feasibility, and the use of video links for work-familiarisation and case manager support. In Paper III, in-depth interviews were conducted using purposive sampling from the cohort, targeting individuals who had either returned to work or had not, based on baseline and six months follow-up data. These interviews were transcribed verbatim and analysed using the Framework method to describe the perceived facilitators and obstacles of returning to work. Results: The intervention material was culturally adapted and translated and found to be of high quality, acceptable, and valued by 45 Norwegian end-users. In the pilot study, 55 participants were included, with 19 being offered the intervention, and eight consenting. Data collection, randomisation, and video-link use were feasible. Challenges included limited recruitment sources, low intervention acceptance rates, and the time-consuming process of identifying and placing participants in work placements. Three participants received a work placement offer, with one completing the placement. Of the 29 participants interviewed, 12 had returned to work, and 17 had not. Key themes that emerged around participants’ experiences of obstacles and facilitators, related to the Norwegian Labour and Welfare Administration, healthcare, psychological, pain, and perceptions of work. Participants viewed the Norwegian Labour and Welfare Administration as a major obstacle to returning to work and improving health, citing a lack of personalised support and care, with an over-emphasis on work ability testing causing fear and distress. The healthcare system was perceived as disjointed, with long waiting times and a tendency to dismiss persistent pain. Key facilitators included fortuitous encounters with supportive and empathic welfare staff and personal attributes like psychological flexibility and determination. Some participants cited ‘luck’ and ‘disability pension’ as facilitators to returning to work. Conclusion: The UK intervention material was able to be adapted for use in Norway. Results from the pilot study suggest that the intervention is feasible for delivery in Norway. Challenges related to low intervention acceptance rates and the process of identifying work placements were addressed before proceeding with the full-scale study. Interviewed participants described significant system and contextual obstacles to return-to-work. An integrated, empathetic, and person-centred pathway within the welfare system may better support individuals with persistent pain returning to work.