Development and feasibility test of WORK-ON – a complex vocational rehabilitation offer for people with chronic inflammatory arthritis

Background

Despite major advances in pharmacological treatment, there are still unmet needs among people with chronic inflammatory arthritis (IA), which in this study includes rheumatoid arthritis, axial spondyloarthritis and psoriatic arthritis. Up to 40% of people with IA are intolerant of, or do not respond sufficiently to pharmacological treatment. Even patients considered to be in remission or with low disease activity often experience symptoms such as pain, fatigue, and anxiety, as well as physical and social limitations. People with IA have a decreased ability to work and an increased risk of long-term sickness absenteeism, and up to 38% of them lose their jobs within the first few years of their diagnosis. As a result, people with IA have a high risk of permanent exclusion from the labour market, and they need support to increase their work ability, decrease levels of sickness absenteeism, and reduce the risk of job loss. There have been few studies involving vocational rehabilitation (VR) for people with IA, but results indicate that VR may decrease sickness absenteeism and job loss, and increase work ability. Therefore, the overall aim of this PhD study was to develop and test the feasibility of a new early VR for people with IA.

Methods

The overall methodology in this PhD study was based on the International Classification of Functioning framework and the framework for development and evaluation of complex interventions, as described by the British Medical Research Council. 

The aim of the PhD study was achieved via three studies:

1) Semi-structured individual interviews with people with IA, to explore the perceived challenges at work and identify needs for professional support.

2) Development of a VR, WORK-ON by generating context-specific evidence and co-creation. WORK-ON was developed using the following: existing evidence; the concept self-management; theories of occupational balance and shared decision making; the results from Study 1; interviews with rehabilitation clinicians (RCs) and employers; and a workshop involving patients, RCs, and researchers. We produced a manual using an iterative process, and developed a logic model to describe the mechanisms of impact and to define relevant outcomes.

3) Testing the feasibility of WORK-ON focusing on the recruitment procedure, intervention fidelity, and outcome measures; evaluating the most suitable primary outcome measure to use in a subsequent randomised controlled trial (RCT). A six-month feasibility test with no control group was performed.

Results

Study 1: The participants were 11 women and 4 men with IA (aged 36–68 years) who worked full-time or part-time, or were on short-term sickness absenteeism. The analysis revealed a major theme, achieving balance in everyday life, and four sub-themes: 1) working despite challenges; 2) prioritising energy for work; 3) fatigue leading to lack of control; and 4) the need for flexibility and recognition. 

Study 2: A manual was developed to describe the background and the content of the six-month WORK-ON. The intervention consisted of the following four parts: 1) a coordinating occupational therapist experienced in rheumatology rehabilitation performs an initial assessment and sets goals in collaboration with the participant; 2) the same coordinating occupational therapist provides individually tailored support throughout the intervention, including support in navigating the primary and secondary healthcare systems, 3) three group sessions with presentations and discussions to facilitate peer support, and 4) individual VR consultations with a PT, a nurse, and/or a social worker, depending on the participant’s needs. Relevant outcome measures to test in the subsequent feasibility test were identified, based on the aims, theories, and content of the VR WORK-ON, in accordance with the logic model. The primary outcome to be tested was work ability, measured using the Work Productivity and Activity Impairment questionnaire and the Work Ability Index single item. The secondary outcomes were occupational balance, health related quality of life, the number of days of sickness absenteeism, pain, fatigue, physical activity, and mental well-being.

Study 3: We identified 119 potentially eligible patients with IA from May 2022 to October 2022 using question number #6 from the Work Ability Index Questionnaire: ‘Do you believe, according to your present state of health, that you will be able to do your current job two years from now?’ In total 19 patients (17 women and 2 men) were included and they completed the six-month WORK-ON intervention. The mean age was 53 years. Preliminary results indicate that at six-month follow-up, there was a slight tendency to improvement in work ability, quality of life, and level of physical activity compared to baseline. Furthermore, the participants reported less pain. In total, 10 of the 19 participants reported an increase in sickness absenteeism during the six-month intervention. None reported a decrease in sickness absenteeism. 

Conclusion

WORK-ON is considered to be an acceptable and feasible intervention and has the potential to increase work ability among people with IA who are concerned about their future ability to keep working. Though, an adjustment of the intervention is needed before a randomised controlled trial. A longer follow-up period is needed to evaluate whether the intervention can reduce job loss. Based on the results from the feasibility test, the intervention will be adjusted and tested in a randomised controlled trial. In case of positive results a cost-effectiveness analysis will be included.