Opportunities, barriers and facilitators of an indicated prevention strategy to prevent future long-term sickness absence in SMEs: A qualitative study

1Introduction

Long-term absence due to sickness (hereafter: long-term absence), often defined as absence from work longer than six months due to sickness [1], remains an important concern given that long-term absence is highly costly to employers, employees, and society at large [2–4]. In the Netherlands, in 2016, about 1.6% of all employees were sick-listed for a long period, which was an increase of 32% compared to the rate of 2013 (1.2%) [5]. Previous studies have shown that long-term absence may be a pathway to future work disability, early retirement, and unemployment [6], which is at odds with European Union (EU)-wide efforts directed at increasing the workforce participation of all working-age people [7]. For employers, long-term absence may cause a disruption involving financial and operational implications like productivity loss, costs for replacing employees, increased insurance premiums and may also affect overall levels of job satisfaction and turnover among employees [8]. The financial ramifications of long-term absence may be particularly high for employers in countries like the Netherlands, where employers are held responsible for paying the salary of employees on sick leave for a period (at least 70% for a maximum period of two years in the Netherlands). So employers have an important stake in preventing long-term absence among their personnel.

Prevention of long-term absence has been covered by either universal preventive actions focused on health protection and promotion targeting health and work-related factors of all employees [9], or by designing workplace-based policies to facilitate return to work of workers on absence [10]. Yet, although substantial research has focused on the effectiveness of such programs, only a few (high-quality) workplace-based return to work programs have demonstrated their effectiveness [11]. Against this background, an indicated prevention strategy that focuses on employees with a high risk for future long-term absence may be a viable alternative [12, 13]. When employees have a high risk for a presumable future encounter of an episode of long-term absence, they are subject to early intervention [14]. In this sense, “early” refers to intervening before actual sick leave has occurred. Several indicated prevention strategies have proven to be effective for predicting and preventing future absence [15, 16]. Such a strategy has also been developed earlier by Maastricht University jointly with the Occupational Health Service “Beter.” This strategy comprises two elements: (1) screening based on a validated screening questionnaire—the Balansmeter—which enables identification of employees with a high risk of future long-term absence [17, 18] and (2) subsequently providing the high-risk workers with an early consultation with their occupational physician or another occupational health professional. The questionnaire comprises questions on the work environment (e.g., working conditions and psychological job demands), characteristics of employees’ private situation (mental), health status, demographic factors, and absence history, and it is protected by medical confidentiality. Questions are predictive for future sick leave. Using a specific algorithm, employees’ individual risks for future long-term sick leave, here defined as a consecutive period of more than 28 days of absenteeism, are calculated. Employees at high risk for future long-term sick leave are invited for extensive, one-to-one consultation with an occupational physician or another occupational health professional. The structured early consultation involves several steps, during which the results of the screening questionnaire are discussed and a broad range of additional anamneses can be performed to consider options for treatment or guidance. Although the efficacy of this preventive strategy has been demonstrated in two large randomized experiments in a multinational organization [12, 19, 20], the preventive strategy has not been applied across different organizational settings, like those of small and medium-sized enterprises (SMEs), or companies with 250 employees or less. Yet, SMEs have a share of about 70% in the total employment level in the Netherlands [21] and could benefit substantially from this preventive strategy. Before effectiveness can be demonstrated in this setting, adequate adoption and implementation of this strategy are imperative. As multiple stakeholders like employers, employees, and occupational health professionals are involved and need to align their interests and collaborate, recent research has been concerned with identifying the factors for successful adoption and implementation of this preventive strategy [22, 23], but only for multinational companies.

Compared to multinational companies, the long-term absence of employees with key expertise may pose a direct threat to the business of SMEs, as internal successors for those positions are often lacking, or difficult to find in the external labor market. In addition, SMEs tend to have fewer options to adapt working requirements and circumstances to ease their return to work [24]. Also, financial responsibilities related to the continuation of salaries, and the hiring of external replacements tend to be a burden on the company’s total wage sum. Simultaneously, SMEs generally possess fewer resources to organize the protection of occupational health for their personnel [25]. They are more frequently characterized by a “structure of vulnerabilities” [26–28], implying less knowledge and resources to manage the work environment properly for record-keeping and inventorying costs, and a lack of experience due to the shorter life cycle of SMEs compared with larger companies [29, 30]. Hence, potentially, there is a strong business case for an indicated prevention strategy in SMEs. Yet, to date, it remains unclear whether SMEs would perceive such a strategy as a viable option and what they might anticipate as possible barriers and facilitators to implementation in an SME context.

First, SMEs tend to have a more defensive attitude toward buying-in external preventive services, and also make less use of publicly available preventive services in general [26, 27, 31–33]. Specifically, concerning SMEs’ decision-making process on whether to take precautionary actions to combat absenteeism, research has shown that such a decision largely depends on the degree to which SMEs regard absenteeism as related to working conditions [34]. In general, occupational health and safety issues tend to be seen as an individual rather than an organizational issue in SMEs [25]. This externalization of organizational responsibility may therefore be considered a specific barrier for the implementation of the indicated prevention strategy earlier introduced, as the preventive strategy also implies the shared responsibility of the employee and the employer. Also, barriers and facilitators in a multinational setting, such as having a culture of health and conceptions about the responsibilities of both employers and employees [23], may not be generalizable to the setting of SMEs. Barriers in SMEs may have to do with issues like defensiveness because of the strong identification of employers with their business. Moreover, guaranteeing the privacy of participation in such interventions may be challenging because in SMEs, the employee–employer relationship is more informal [32]. Despite differences, there may also be similarities with larger companies; for instance, facilitators of implementation may concern anticipated positive consequences for workers’ wellbeing or reduction of absence related costs [35, 36]. Generally speaking, practical solutions that can be easily integrated into the workflow without any major costs are considered more acceptable for SMEs [25, 33].

This study aims to investigate the opportunities, barriers, and facilitators, as anticipated by management and employees, to implement the specific preventive strategy regarding SMEs. The perspective of employees in addition to that of management is of importance in SMEs, as employee involvement is more direct (less unionization) and relationships in small workplaces occur on a more personal basis [37]. Hence, a qualitative needs assessment was conducted to inventory anticipated opportunities of this strategy, barriers, and facilitators of its implementation and underlying existing conceptions on the causes of absence and the responsibilities of the stakeholders involved (management and employees). As SMEs employ 67% of all workers in the EU [38], insights gathered in this study may provide clues for a wider and optimal implementation of a scientifically proven strategy on indicated prevention for long-term absence. Hence, this study also aims to follow up on calls for more attention to preventive policies aimed at maintaining and promoting labor force participation [39].

2Methods

3Results

4Discussion

This study aimed to identify the facilitators and barriers for the adoption and implementation of an evidence-based indicated preventive strategy for the reduction of future long-term absence regarding SMEs. Recent studies have been concerned with identifying the factors for successful adoption and implementation of this preventive strategy [22, 23] in large international companies, but not in SMEs.

Overall, the results indicate that employers in our study had positive expectations concerning the gains of the preventive strategy. Employees were somewhat more reserved as they emphasized fulfillment of several conditions for the gains to occur. In general, respondents had a favorable reception of the preventive strategy, earlier unknown to them, as only two employers had no intention to implement the preventive strategy and none of the participating employees would refute participation upon invitation. These findings corroborate with earlier research that SMEs are also sensitive to the positive consequences like workers’ wellbeing or reduction of absence-related costs when considering the implementation of strategies in the area of employee health and absence [35]. Compared to multinational companies, SMEs often lack a “culture of health” (characterized by values and activities directed to employee health) [23]. Yet, important drivers enabling the success of initiatives like the preventive strategy are, according to respondents, primarily based on shared responsibility and trust.

One key barrier widely shared across employers and employees concerned lack of confidentiality. This was also a concern for multinational companies in previous studies [22, 23], maybe even more in SMEs given the personal ties employers and employees have. Also, some employees questioned whether confidentiality would be feasible as regards SMEs, which probably relates to the more informal modes of employer–employee exchanges that they are acquainted with [32]. This barrier is likely to have ties to other barriers, such as unintended consequences of which stigmatization and discrimination following being screened as high-risk for long-term absence. An important addition from the employee focus group was the role of the occupational health professional. A minority of employers had concerns regarding occupational health professionals’ lack of proactivity or ability to tune in on employees, whereas employees in general did not associate an actor like the occupational physician with the prevention of absenteeism or early intervention. Clearly, there is a difference in expectations between employees and employers on the role of occupational health professionals like the occupational physician. Also, the role of the occupational physician is seemingly received more critically in SMEs than in multinational companies [22, 23]. An implication for the successful implementation of the preventive strategy is that the role of the occupational health professional in the prevention of absence should also be well clarified to all stakeholders. Nevertheless, concerns regarding the independent role of the occupational health professional are to be taken seriously, as they may be based on earlier experiences and/or have to do with the intertwining of interests like income insurance and occupational health care in SMEs.

Convergence between employees and employers also shows itself in other barriers, of which parties seem to stress related facets from their perspective. For instance, employers see lack of capacity (i.e., financial and non-financial resources) as the most important employer-related barrier for the preventive strategy. Simultaneously, from the employee perspective, lack of follow-up on behalf of the employer was considered a serious barrier. These findings can probably be linked to the scarcity of resources in SMEs to manage the work environment properly, as compared with larger companies [29, 30], and their orientation to more practical solutions that can be easily fitted in SME’s workflow [25, 33]. Also, employees sense such an orientation in their company, i.e., solving problems when they are encountered.

Throughout the interviews, employees and employers mentioned several issues that remained unclear (e.g., the “what,” “why,” and “when” of the benefits and costs or methodology (e.g., questions in the screening questionnaire), or reporting of feedback), which, if unaddressed, will act as barriers. These issues are likely to be resolved by providing employers and employees with more information, which was, in the context of this study, only provided in a very basic form. Receiving more information was also named by employers as an important facilitator.

More difficult to address are underlying beliefs that have ties to the adoption and implementation of the preventive strategy. Our analysis reveals that employers’ viewpoints on their responsibility for employees’ health and absence are connected with their intention to implement the preventive strategy. Employers who acknowledged the (shared) responsibility of the employer concerning absence or employee health were also more inclined to implement the preventive strategy, whereas those who were less eager to implement the preventive strategy emphasized the individual employee responsibility. Typically, non-implementers felt that the factor, work, compared to non-work-related causes of absence is overrated and that impaired health was more often explained as a consequence of poor lifestyle choices for which the employee can be held accountable. In contrast, employers who were inclined to implement the preventive strategy all acknowledged the importance of work-related factors for employee health and absence. Simultaneously, employees themselves also felt primarily responsible for their own health. Absence is differently appraised compared to health; employees acknowledge a shared responsibility: the employer is responsible for the working conditions and the employee to appropriately respond to what the employer provides in and one’s own health. One implication for the successful implementation of this preventive strategy is that the employer responsibility could be encouraged but without detracting from the personal responsibility that employees experience and value, as also found in other studies on the introduction of work-site health interventions [42]. A second implication for successful implementation is that the dichotomy between the work-and non-work-related roots of employee health and absence should be bridged. This duality does not align with scientific evidence and frameworks like the International Classification of Functioning, Disability and Health (ICF) that propagate the complex interplay of both work-and non-work-related factors regarding an employee’s health and functioning [9, 43, 44]. Relatedly, it should also be noted that when it concerns the causes of health and absence, employers and employees stress the physical working environment and lifestyle factors in their narratives. The psycho-social dimension in both the causes and the nature of health and employee functioning remains underexposed in their narratives. These divides could hinder the adoption or implementation of preventive strategies because they may lead to unfruitful discussions, such as making the financial cost of participating in the preventive strategy dependent upon the assumed roots of the “problem” as either work-related or personal. Besides that such beliefs may keep employee barriers relating to the financial aspect vivid, it may also create unrealistic expectations concerning feedback to employees (i.e., whether the problem is work or non-work related). Personal feedback is an important facilitator for employees and employers but should be realistic and match with what the underlying science can provide.

Concerning feedback, several misconceptions are also noted. Employers preferably would be informed sooner about possible (hidden) problems leading to possible absenteeism and act upon that information. Yet, the screening questionnaire cannot indicate what the specific problem is, nor can the answers of employees be shared with employers, as these are protected by the medical confidentiality of the occupational health professional. In addition, concerns like the unintended consequences of filling in a screening questionnaire (e.g., “I have something, so I’m sick”) are misconceptions based on the idea that individuals without any clarification by a trained occupational health physician would be informed about their high-risk status. Also, occupational health professionals can address a person’s health beliefs or experience of anxiety following a positive test result. Addressing these possible misconceptions in advance by transparent communication to all stakeholders and supporting SMEs in their communication to employees will be a key to the successful implementation of the preventive strategy. A leaflet is unlikely to suffice; potentially, trajectories may kick off with a start-up meeting organized on the premises of a company, open to employees, and involvement of the researchers may be a good start. A related idea was raised during the focus group.

However, this study also has several limitations. We only included employees from one SME and did not incorporate other relevant stakeholders like the occupational health professional in this study. Our primary group of stakeholders was the management of SMEs, as their opinions on opportunities, barriers, and facilitators are the first hurdle to any implementation in practice. For that reason, our primary data concern the 15 interviews with managers, and the focus group with employees should rather be seen as the first complementary exploration of the views of another relevant stakeholder. Currently, insights that stem from the focus group do not give a widespread understanding of employees’ perspectives, and future research should investigate this stakeholder group more in-depth. Also, focus groups are different from individual interviews, as deviant personal opinions may be obscured by the majority group. As the information we gave to respondents on the preventive strategy was minimal, we could not always establish whether barriers and facilitators were tied to one of the specific steps of the preventive strategy (i.e., the screening questionnaire or the early intervention), specifically. Also, it may have led to an overreporting of barriers, in particular, concerning unclear issues of the preventive strategy. Participating companies are not representative of SMEs in the Netherlands, or even Limburg, although the representation of various typical industries (e.g., transportation, agriculture, and industry) was sought after. The picture that emerges from this study is likely to give a broad overview of all possible views on the opportunities, barriers, and facilitators linked to the preventive strategy. Concurrently, it is likely that the salience of particular issues may be different in specific sectors. The generalizability of our findings is further limited to countries in which the employer is responsible to pay for sick workers (like Finland and Norway) and has a stake in preventing absence by implementing an indicated prevention strategy. In countries where the responsibility for absence and the costs are shifted solely toward employees and society (like Belgium), employers will probably have no/limited incentive to implement a strategy directed at the prevention of future long-term absence. Also, the role of the occupational physician in the prevention of absence is typical for the context of our study.

5Conclusion

Overall, this study provides insight into the possible barriers and facilitators that employers and employees of SMEs anticipate when considering the implementation of an indicated prevention strategy to prevent future long-term absence. Furthermore, the detailed picture of possible barriers and facilitators gives clues for a wider and optimal implementation of this scientifically proven strategy from which more employees could benefit. Also, this study has shown that this is unlikely to only constitute quick fixes of loosely coupled barriers and facilitators, as our results also demonstrate how these have roots in beliefs about responsibilities and of the factors responsible for employee health and absence. For future research, it is recommended to study the employee perspective in more depth and to consider other stakeholders, such as occupational health professionals.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

None of the authors have any conflicts of interest to report.