title: Active sick leave for patients with back pain: all the players onside, but still no action.
abstract: METHODS
  Semistructured interviews, group discussions, and a mailed survey.
  
  
  OBJECTIVE
  To identify barriers to the use of active sick leave (ASL) and to design an intervention to improve the use of ASL by patients with low back pain.
  
  
  BACKGROUND
  ASL was introduced in Norway in 1993 to encourage people on sick leave to return to modified work. With ASL the National Insurance Administration (NIA) pays 100% of wages, thereby allowing the employer to engage a substitute worker at no extra cost, in addition to the worker on ASL. Arranging ASL requires cooperation between the general practitioner (GP), employer, local NIA staff, and the patient, which may explain why ASL was used in less than 1% of the eligible sick leave cases in 1995, despite strong support from all players.
  
  
  METHODS
  The authors conducted five in-depth interviews at a workplace where ASL was successfully implemented. Questionnaires were sent to 89 GPs, 102 workplace representatives, and 22 local NIA officers in three counties. Five patients with back pain who had used ASL were interviewed in a focus group, and 10 patients with back pain who had not used ASL were interviewed using a structured guide. Five workplaces participated in a dialogue conference. Data collection and analysis were iterative, and new data were constantly compared with the previously analyzed materials.
  
  
  RESULTS
  About 80% of the GPs, employers, and NIA officers believed ASL is effective in reducing long-term sick leave. Among the barriers identified were lack of information, lack of time, and work flow barriers such as poor communication and coordination of activities between the players required to carry out ASL. Two strategies were designed to improve the workflow between them. A passive implementation strategy was designed to require a minimum amount of economic and administrative support. It included targeted information, clinical guidelines for low back pain, a reminder to GPs in the sick leave form, and a standardized agreement. A proactive strategy included the same four elements plus a kick-off continuing education seminar for GPs and a trained resource person to facilitate the use of ASL.
  
  
  CONCLUSIONS
  Having all the players onside may be essential, but it is not sufficient to bring about action in workplace strategies for patients with low back pain. If early return to modified work is effective, implementing it may require interventions targeted at identified barriers.
authors.affiliation: Health Services Research Unit, National Institute of Public Health, Oslo, Norway. inger.scheel@folkehelsa.no
authors.forename: Inger B
authors.initials: IB
authors.lastname: Scheel
authors.forename: Kåre Birger
authors.initials: KB
authors.lastname: Hagen
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Oxman
mesh_terms: D003142:Communication; D019538:Health Care Surveys / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D017116:Low Back Pain / Q000453:epidemiology / Q000534:rehabilitation*; D009313:National Health Programs / Q000706:statistics & numerical data*; D009664:Norway / Q000453:epidemiology; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D018582:Sick Leave / Q000191:economics / Q000706:statistics & numerical data* / Q000639:trends