How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework

Abstract

Purpose. Under the national framework law in Sweden, all eligible people should have equal chances of receiving vocational rehabilitation. We aimed to review the evidence on (1) whether access to vocational rehabilitation is equitable in practice and (2) whether the outcomes vary for different groups in the population. Method. Systematic review of studies in Sweden that reported diagnostic or socio-demographic characteristics of people offered or taking up rehabilitation programmes and outcomes of such programmes for different diagnostic and sociodemographic groups. Searches of 11 relevant electronic databases, 15 organisational websites, citation searching and contact with experts in the field, for the period 1990-2009. Results. A total of 11 studies were included in the final review, six of which addressed review question (1) and seven addressed review question (2). All the six observational studies of access reported biased selection into vocational rehabilitation: greater likelihood for men, younger people, those with longer-term sick leave, those with lower income, employed rather than unemployed people and those with musculoskeletal and mental disorders or alcohol abuse. Having had a rehabilitation investigation also increased the likelihood of receiving vocational rehabilitation. Differential outcome of rehabilitation was reported in seven studies: outcomes were better for men, younger people, employed individuals, those with shorter sick leave and those with higher income. Selection into vocational rehabilitation was perceived as important for successful outcomes, but success also depended on the state of the local labour market. Conclusions. There is evidence of socio-demographic differences in access to and outcomes of vocational rehabilitation in Sweden, even though the national framework law is meant to apply to everyone. Few studies have deliberately measured differential access or outcomes, and there is a need for this kind of equity analysis of population-wide policies. Studies evaluating the effects of vocational rehabilitation must consider selection into the programmes for adequate interpretation of impact results.

Prognostic Factors for Return to Work, Sickness Benefits, and Transitions Between These States: A 4-year Follow-up After Work-Related Rehabilitation

“…Our finding, that long sick leave length before referral to the rehabilitation clinic was a strong risk factor for not returning to work, for receiving medical and vocational rehabilitation allowances, and for DP during follow-up is in accordance with the literature [1, 5, 19, 21]. The probability for transition both from and to work during follow-up was highest for those with the shortest sick leave spells, indicating that short sick leave spells may be a risk for new sick leave spells.…”

“…In this study, we did not find any association between young age and RTW after the rehabilitation program, but it was a higher probability for being on vocational rehabilitation allowance for those with younger age. In a Swedish study, RTW after vocational rehabilitation was found to be higher for the younger age groups, particular for those below 40 years [1]. However, vocational rehabilitation allowance in Norway may differ from vocational rehabilitation Sweden.…”

“…Thus, results seem to differ between populations and studies and there is still no consensus in how to understand the gender divide in sick leave and DP. Studies on prognostic factors for RTW after diverse work-related rehabilitation interventions, show contradictory results between genders, some with better outcomes for men [1, 35], some with better outcomes for women [23], and some with no gender differences in outcome [5, 13]. …”

“…Knowledge about prognostic factors for work resumption after rehabilitation is still limited, and we do not know which patients will benefit most from comprehensive work-related rehabilitation efforts [1]. Additionally, there is a lack of agreement regarding when and how work resumption should be measured [2, 3], and little is known about the long-term work outcomes after work-related rehabilitation [4, 5].…”

“…Norwegian women have a higher rate of sick leave and DP than men, and still little is known on this gender divide [16, 17]. Female gender [1, 4, 18] and higher age [1, 19, 20] predict lack of RTW. Length of sick leave before rehabilitation [1] and sick leave in itself, are considered to be important risk factors for delayed RTW [19], and for future DP [21].…”