Social Factors of Sickness Absences and the Significance of the Nature-culture Interplay in Coping.

CONFLICT OF INTEREST: none declared. AIMS: The aim of this study was to focus on and to discuss how social factors influence sickness absence. There were two aims of this study: a) To explore and reveal the absentees experiences and perceptions of sickness absence in daily life b) To explore and reveal the absentees own perceptions and experiences of coping while being on sickness absence. Methods. Qualitative method through a pragmatic synthesis of elements of ethnography and grounded theory were used. The sample from the county of Oppland, Norway (n=30) had a mental or a musculoskeletal diagnosis in accordance with the ICPC-2 medical classification system. Results. The interplay between working conditions and private life burdens has an impact on the development of illness and sickness absence, reinforcing the perception of a total life burden situation for women; including caring responsibilities. Men experience stress and conflicts at work, mostly from the leadership and its organizational structure. The majority of the sample used different techniques and strategies to cope with their illnesses, highlighting the significance of the nature-culture interplay. Conclusion. A holistic approach that considers the whole life situation must also be considered in order to understand gender differences in sickness absence. The importance of being involved in daily activities, and feelings of belonging to a social network were important for both men and women. This research may also add important awareness and understanding of Nature-Culture-Health (NaCuHeal) benefits in public health.

1. INTRODUCTION

Current research on sickness absence due to musculoskeletal or mental diagnoses

Social factors of sickness absence are recognized as important, and in the scientific discussions as well as in medical practice, the influence of social factors has been accepted for decades. The growth and acceptance of the disciplines of medical sociology and social medicine can be seen as a symbol of this development (1). A recent study by Eriksson (2) has suggested that the course of events leading to sickness absence due to burnout might be understood as a process of emotional deprivation, where the individual is gradually emptied of the life-giving emotional energy that is expressed as joy, commitment, and empathy. This process can be viewed in connection with ongoing conflicts, which arise as a result of organizational changes at work that have continued to escalate (3). In order to understand the social situation for the sickness absentees it is important to consider how identities and relationships are formed in interaction with other people. Mental illness seem to be increasing in Europe (4), and there are global trends towards increasing stress and ill-health at work (5). The organization of work is not the only important factor for employees’ health; the quality and value of social relations is also significant for the occurrence of mental illness (Eriksson et al 2011). Problems or worries in the family have been reported as contributory factors resulting in sickness certification by 12% of the patients at work, and problems/worries during leisure time by 7% (6).

The role and significance of nature-culture- health interplay

Previous research shows how individuals’ sense of coping coincides with their ability to develop a stronger self, sustaining control over everyday problems, hence their own progress. There is a growing body of scientific evidence in support of the value of the arts for health (7- 11). A common theme, including a recent study from a rehabilitation centre in Norway, is that nature-culture-health experiences may, from a salutogenic perspective (12), help participants to construct a meaning, to identify coping mechanisms, and to revitalize the energetic and resourceful parts of the self (13).

Aims

The purpose of our project is to focus on and to discuss how social factors influence sickness absence. There were two aims of this study: a) To explore and reveal the absentees experiences and perceptions of sickness absence in daily life b) To explore and reveal the absentees own perceptions and experiences of coping while being on sickness absence.

2. METHODS

2.1. Study design

Our study concentrates on two main groups of diagnoses: musculoskeletal and mental disorders. This study takes an exploratory approach, examining a research area where there has been little data and building upon work that has focused on sickness absence as a phenomenon. This research methodology was inspired by grounded theory (14, 15) suited to the study of informants’ own experiences and practices by using an openended interview guide. This notion of flexibility is important to let themes emerge from the informants’ own accounts (16). In this way it provides a means for exploring correlations between sickness absence and health by helping to uncover the ways in which the illness experience are understood and experienced by actors themselves.

2.2. Analysis

Following principles of grounded theory (14) the analysis took a qualitative approach to data based on inductive procedures for obtaining emergent themes (17, 18). Through the process of coding, categorization, and comparison the interview data within one participant and/or among the sample as a whole, one could detect recurrent themes, patterns and tendencies. The first major analytic phase of the research consisted of coding the data through open coding (14, 15) in order to identify descriptions of thoughts and ideas related to our open-ended interview guide. Moreover, to generate categories and subcategories, ‘focused’ coding was used to compare between incidents, contexts and situations, and connections between incidents, situation and categories were explored. The emergent codes are grouped together into abstract categories, then developed and saturated (14). For example how does the research participant think, feel and act while involved in the process of being long term ill: when, if, why and how they decide, for example, to use physical activity, art or nature walks as a way to recover or cope with daily life. How do they explain and perceive their illness experience in relation to everyday life.

2.3. Sample

The interviewees were selected from the Norwegian Labour and Welfare Administration [NAV] in Norway, following the inclusion criteria: an employed woman or man between 20-50 who has an ongoing sickness absence period exceeding 31 days or a currently expired period, with a mental or a musculoskeletal diagnosis in accordance with the ICPC-2 (medical classification system). The sample was selected from the county of Oppland, and 30 Norwegians (20 women and 10 men) made contact with the researches through phone or e-mail before the interviews were conducted. The willingness and motivation from the informants to dedicate time and effort to the study can be described as a convenience sample (14).

The informants were distributed as follows: Two men were in their thirties, five men in their forties and three men were in their fifties. Among the women seven were in their fifties, and eight in their forties. Three women were in their thirties and two were in their twenties. Out of the total sample (n=30) seven men and nine women were diagnosed with mental illnesses; hence depression and anxiety or burn out (n=16) and three men and eleven women (n=14) had musculoskeletal diagnosis. Before the interviews, all participants were informed about full confidentiality and about their right to break off participation at any time. The participants were asked to sign an informed consent document. The interviews lasted for about one to two hours per informant, audio-taped and transcribed verbatim. Fictive names are used.

3. RESULTS

3.1. Overview

It seems to be that the interplay between working conditions and private life burdens has an impact on the development of illness and sickness absence, reinforcing the perception of a total life burden situation for several informants. However there seem to be some gender differences. Furthermore, social network at work or in private life, and having meaningful activities, for example nature walks, close contact with animals or using music were not dependant on their diagnoses or gender, but the ability to personally choose the most suited activity that seemed most attainable and pleasurable. Additionally, it also seemed that the combination of different activities gave a holistic feeling for both men and women. This notion may in turn have a positive effect on their self-efficacy and may empower their feelings of coping.

3.2. Women, double exposure and health

For women with musculoskeletal problems; strains and burdens in both working- and daily life along with a lack of energy were important. For women with mental diagnoses; problematic life events, often in connection with their upbringing or heavy caring responsibilities were vital. There were two aspects related to how women coped with their illness and life situation; to what extent they had a supportive and caring network at work or in private life, and to what extent they had meaningful activities that seemed to help them cope with their life situation. It looks as if women who have been exposed to relational problems and conflicts, quite often have experienced mental health problems and illnesses over time. Doris (age, 35) has experienced a demanding life situation with little support, being a single-mother and having a strenuous job: “I worked and made meals for the kids, a very boring life...I had a very boring life..and I realized I couldn’t manage. When the work load gets too heavy, it’s the job that suffers, and I needed a long break (musculoskeletal disease). Additionally, some of these women have had various personal crisis due to their children’s severe illnesses, drug problems and sexual harassment. Cora (age 39) describes how she felt a sudden burn-out and how her illness progressed highly unexpectedly. She elaborates her problems as caused by an authoritative grandfather during her upbringing. Due to her illness her marriage became problematic and being a mother to two children, she felt guilty that her caring responsibilities was insufficient and inadequate: It came very sudden, I felt I hit the wall, and I couldn’t manage to go to work, and this came as a shock, and then the feeling of shame. The reasons behind my depression, I think, is due to my grandfather who was very authoritative, and I lack self-confidence. It was so scary being so ill, like a big gap.

3.3. Men, work and conflicts

For men with musculoskeletal problems; there seem to be two different types of work-related problems; strains and burden over a longer period of time or accidents related to work. For men with mental illness; organizational or structural changes or conflicts at work seems to be of importance. Several men in this study had a stressful job with little control and flexibility. Several male informants tell stories of how strong and inhumane pressure at work can lead to conflicts between the leadership and the employees. Paul (age 42) who has worked at the same company for many years, observed how the staff were reduced and how employees felt difficulties in coping with the ongoing changing realities at work: Quite often we read in the newspaper about changes at our work before we are informed about cutbacks in staff. We always get negative criticism and feedback from the leadership, and they always pinpoint on how we all should achieve better, be more productive and earn more money for the company like machines we are... The type of deteriorating processes makes individuals vulnerable for developing ill-health. In a situation were one might be feeling ill or stressed, a sudden, dramatic event in their lives may only add to a complicated life situation. If the employers are indifferent or show little understanding for the health situation, a sick-leave or even a resignation may be a result. Strong pressure at work may lead to lack of motivation for work, and along with a negative spiral of deteriorating processes, the employees run the risk of being long-term ill. These social processes at work seem to be followed by lack of motivation and fatigue by the employees. These elements are illustrated through Tony’s voice (age 59): I remember so well the day before I went on sickness absence... I had some relatives visiting and we were going to have a nice week-end, and I felt so tired and deflated, and during the night I said to myself, that this can’t go on....I realized my limits...If a leader does not follow up an employee who has developed health problems due to psychosocial factors at work, this may lead to an extended period of sickness absence and possibly a signing up; After I had been on sickness absence for a long time, I felt that the cup was full and I had to resign..

3.4. Strategies of coping for men and women

The majority of the sample used different techniques and strategies to cope with their illnesses. The importance of being involved in daily activities, and feelings of belonging to a social network were also a recurrent theme among men. Reading literature, gardening, painting and creative arts and handicraft, along with close contact with animals and pets as a therapeutic remedy was pointed out by several informants, and by more women than men. Cats, dogs or horses, were mentioned among a few informants who felt miserable and lonely, had pain or aches. For a few informants walking, sitting in the sofa or lying in bed were combined with listening to music. Brigid, (age 29), says she has deliberately used her horse as a remedy for her depression, finding this activity helpful to structure her life giving, it a sense of meaning. The horse has really been very helpful, I ride, and it works.. it makes me get out, and I don’t have any bad conscience, the horse really gets me going…(mental illness). Anna (age, 39) says she uses nature, literature and physical activity to help her go through her mental processes of being ill, thus helping her to retrieve herself. She explains how nature experiences gives her feelings of calmness, and energizes her…I walk in the mountain and this activity functions as a pool from which I can both learn and retrieve resources, trying to recover…(mental illness).

There might be several reasons behind their explanations as to how and why nature-culture activities seemed to play a role in their lives, hence worth using time and effort on; I use the nature quite a lot, and it has been very helpful to me, and also music, poems, something to rest my head in, makes me calm or gives me energy (Linda, age 41, musculoskeletal disease). As Susan says; (age 41, mental illness) I am trying to do some walks regularly, or even jogging, and it helps me to get going, you know. Mark (age 43, mental illness) says that regular nature walks gives him predictability, energy and time to think and reflect: I think it’s very important to plan ahead, and I find nature walks as energizing, and it gives me time to think and reflect. On the whole, it also seems important for several informants to do activities they enjoyed previously, and felt that they could master, giving moments of pleasure.

4. DISCUSSION

4.1. Methodological considerations and limitations

The research data needs to be set in context. It was collected from the population of a mid-eastern region of Norway comprising the county of Oppland. In line with a qualitative approach, any conclusions drawn from the sample cannot be generalised to the population as a whole, though through a series of similar studies more general conclusions may well emerge. A convenience sample is not statistically representative; nevertheless, some tentative general conclusions may be proposed. One would think that being ill demands a certain amount of energy, and one may assume that some individuals were too ill to participate in the study. Moreover, some individuals may not be interested in participating in research concerning their own illness and health. In addition, the role of being certified sick may influence individuals’ sense of being stigmatized (18).

4.2. Validity and reliability

The fact that each participant was only interviewed once might have contributed to minor trust and confidence between participants and the researcher. One could have prevented the dangers involved in one-off interviews by additional interviews per informant. Another aspect of one-off interview is the inability to check certain accounts or repeat questions, helping to clarify and identify emerging and recurrent themes, issues and topics. In this sense, the identified categories may have lacked saturations, hence trustworthiness due to one interview per participant.

However, the impression was that the informant’s beliefs and opinions were genuine and real, though their verbalism did vary. This study employs subjective self-report, and the data relies on people to accurately report their experiences and perceptions on the issues illness, health, sickness absence and coping in everyday life. Self-report relies on people’s cognitive processes and their ability to recall information (19). However, self-reported data can be reliable and valid provided that they are elicited with care and interpreted with respect to the conditions to where they were obtained.

In qualitative studies it is important to reflect upon the role of the researcher: i.e. the researcher’s gender, age and personal characteristics have been taken into account (20), and these aspects have been taken into consideration. The interviews were held in private homes, cafes’, libraries and at a research office.

4.3. Social factors of sickness absence

Since women as opposed to men express to a greater extent burdens in their lives, a possible explanation might be the combined impact of domestic responsibilities and job strain, the socalled double exposure (21). This notion of a total life burden perception includes a traditional division of labor in the family, leaving women with notions of little social or practical support. Despite equality in sex roles in recent years, it still seems that men and women execute traditional tasks in the family. Recent studies also show how the family situation proved important, hence indicating that family conditions like cohabitation and the presence of children might add to the workload and stress experienced by employees (1, 22). Most men in this sample have become ill due to work related factors, although a couple of men refer to additional problems due to sudden death in the family. However, it seems to be a strenuous work, high stress levels, low control and little support from the leadership or colleagues that lead to an ill health. In this material these men seem to have lost a social meaning in their job experiences, resulting in a lack of ontological security (23). These factors are also in line with another study (24) which revealed a number of critical phases and events relating to the work environment faced by all the participants. In this study there are many similarities to the “flight of stairs”, sensing their situation as intolerable and unbearable. Being incapable of coping with the deteriorating processes at work, sickness absence was the only option.

4.4. Strategies of coping

There might be several reasons behind their explanations as to how and why social activities and nature-culture activities seem to play such a major role in their lives, hence worth using time and effort on. For example for some women who used music, this framing of music may be conceptualized as a prospective device of agency, a way of cueing or tuning in to the ongoing formation of order, or, more accurately, ‘pools’ of order, locally achieved (9, 25). Additionally, reading, gardening, painting and creative arts and handicraft are cultural activities that seemed to enhance feelings of well-being together with close contact with animals or pets which was named among a few. Previous research also shows how close contact with animals can be a therapeutic remedy. Beneficial factors are reduced stress levels, increased coping capabilities in crisis situations, and strengthening the immune system (26). Research also shows other direct health benefits associated with animal ownership including reduced incidence of heart disease and high blood pressure (27-29).

5. CONCLUSION

Combined with discussion of sickness absence as a phenomenon, we believe our findings can contribute to a wider understanding of sickness absence, the complexity behind the outbreak of long-term illnesses and ways of coping in everyday life. Most men in this sample have become ill due to work related factors, and for women it seems to be the combined impact of domestic responsibilities and job strain, the so-called double exposure. The importance of being involved in daily activities, and feelings of belonging to a social network were important for both men and women. A possible road for future research may be to explore further gender differences and relational conflicts in connection to private life and working conditions. This research may also add important awareness and understanding of Nature-Culture-Health (NaCuHeal) benefits in public health.

Funding

This research was funded by the Norwegian Research Council (NFR). There is no conflict of interest to be declared in this research.