J Occup Rehabil DOI 10.1007/s10926-015-9590-5
Disability Pensions Among Young Adults in Vocational Rehabilitation Arnhild Myhr1 • Tommy Haugan2 • Geir A. Espnes1,3 • Monica Lillefjell1,3,4
Ó Springer Science+Business Media New York 2015
Abstract Objectives Lack of work-participation and early disability pensions (DP’s) among young adults are increasing public health problems in most western European countries. The present study investigated determinants of early DP in young adults in vocational rehabilitation. Methods Data from 928 young adults (aged 18–40 years) attending a vocational rehabilitation program was linked to DP’s recorded in the Norwegian Labor and Welfare Organization registries (1992–2010) and later compared to a group of 65 employees (workers). We used logistic regression to estimate the odds ratio for entitlement to DP following rehabilitation, adjusting for socio-demographical, psychosocial and health-behavior factors. Results Significant differences in socio-demographical, psychosocial and health-behavior factors were found between the rehabilitation group and workers. A total of 60 individuals (6.5 %) were granted a DP during follow-up. Increase in age, teenage parenthood, single status, as well as low education level and not being employed were found to be the strongest independent determinants of DP. Conclusion Poor social relations (being lone), early childbearing and weak connection to working life contributed to increase in risk of DP’s among young adults in vocational rehabilitation, also after adjusting for education level. & Arnhild Myhr [email protected]
Department of Social Work and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
Nord-Trøndelag University College, Steinkjer, Norway
Center for Health Promotion Research, Trondheim, Norway
Department of Occupational Therapy, Faculty of Health Education and Social Work, Sør-Trøndelag University College, Trondheim, Norway
These findings are important in the prevention of early disability retirements among young adults and should be considered in the development of targeted interventions aimed at individuals particularly at risk of not being integrated into future work lives. Keywords Disability pension Norway Pain Vocational rehabilitation Work Young adults Social medicine Epidemiology
Introduction A lack of work-participation and early disability pensions (DP’s) among young adults are increasingly public health problems in most western European countries [1–3], with major consequences for the individuals as well as for society . In Norway, the prevalence of young adults under 30 receiving DP has increased by 34 % during the last decade . Those who become disabled at a young age risk a long life outside of a work environment, resulting in potential health, social and economic consequences throughout life . Non-work participants are found to be worse off under many classical measures of health, such as the range and severity of physical and mental complaints, the perception of happiness, and the rate of mortality, when compared to work participants [5–7]. Furthermore, the Organization for Economic Cooperation and Development (OECD) has pointed out that demographic developments will reduce the number of young people entering the labour market. This may, over time, result in deficits of manpower, making it important to develop new policies to mobilize underutilized human resources and promote work participation . However, jobs need to be sustainable and offer at least a minimum level of quality. A decent living
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wage, opportunities for in-work development, the flexibility to enable people to balance work and family life, and protection from adverse working conditions that can damage health, are all considered of great significance . Several studies have shown that there is an increasing health-related selection out of the workforce, which has a particularly negative effect on people with low socioeconomic status (SES) [6, 7, 9]. This selection out of the workforce is a growing problem in terms of working life and employment conditions in western countries. People with low SES are also found to have a greater likelihood of engaging in a wide range of risk-related health behaviours and are less likely to engage in health-promoting activities . Previous population-based cohort studies have shown that low levels of education [10–14] and occupational social class [11, 15], as well as unemployment  and part-time work  are socioeconomic risk factors for early disability retirement. Mental complaints underlie the majority of medical diagnoses among young Norwegian adults receiving DP’s . Moreover, anxiety and depression are found to be robust predictors of DP’s even in cases where DP is granted due to other medical conditions . A higher incidence of DP’s is also found among single parents [3, 20] and teenage parents . In addition, health-risk behaviours such as smoking  and the use of analgesics/hypnotics  have also been found to be associated with early disability retirement. These findings, related to incidence, early and future DP’s, are in accordance with the notion by Rose  suggesting that social context must be incorporated into explanations about why some people stay healthy while others get sick . Despite the increasing proportion of young adults leaving the labour market at an early age due to DP, few epidemiological studies investigating the determinants of DP have had a focus on young adults in danger. Identification of key health factors that determine early disability retirement among young adults in rehabilitation would help in the design of interventions aimed at young adults particularly at risk of not being integrated into future work-lives. The main objective of this study was to identify factors influencing the likelihood of early disability retirement among young adults in vocational rehabilitation. Based on a socio-epidemiological perspective [7, 23] and empirical findings presented above suggesting that social context strongly influences individual behaviour in this area, we hypothesize the following regarding young adults in vocational rehabilitation: (1) high SES, measured as high levels of education and employment, is a protective factor against early DP; (2) psychosocial risk factors including anxiety and depression, measures of pain, and teenage parenthood are positively associated with early DP; and (3) health-
behaviour risk factors, including the high consumption of drugs and alcohol are positively associated with early DP.
Methods Study Population This retrospective follow-up study included young adults of working age (18–40 years) (N = 928) with chronic ([3 months) non-specific musculoskeletal pain, who were attending a vocational rehabilitation programme at various private rehabilitation centres in Norway during the period 2003–2009. Under the inclusion criteria for participation in the rehabilitation programme, participants had to: (1) receive national insurance benefits in the form of a sickness benefit or work assessment allowance (known as AAP), and (2) have chronic musculoskeletal pain problems. A cutoff age of 40 years was selected on the basis of Brage and Thune’s  classification of young adults. The regular dropout rate of the rehabilitation programme is usually around 6 %, and the majority of the dropouts are men . Additionally, with regard to baseline characteristics, the rehabilitation sample was compared to employees within the same age group and geographic area. The employees (hereafter referred to as ‘‘workers’’, N = 65) were participating in a health promotion programme administered by the same rehabilitation centres. The Vocational Rehabilitation Programme Based on a biopsychosocial model , which assumes that biological, psychological, and social factors are interwoven in the context of chronic disease, the vocational rehabilitation programme consists of up to 57 weeks of rehabilitation, during which the participants attend 6-h rehabilitation sessions 3 days per week. An assessment of functional capacity to perform work is required to maintain the right to financial support in the form of sickness benefits or AAP from the Norwegian Labour and Welfare Administration (NAV). The present rehabilitation programme, funded by NAV as a work-related measure, offered the required assessment, and participants were assigned to the program by NAV in cooperation with a medical doctor (and eventually the employer) . The rehabilitation involved both individual counselling and group-based treatment, with the aims of increasing functional capacity, decreasing affective distress, educating participants about positive health processes, and increasing return to work rates. All participants were assigned a personal supervisor, and individual counselling was offered throughout the rehabilitation period. The intervention has been well described in Lillefjell et al. [26, 27].
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Measures Data Sources The rehabilitation centres have routinely collected data from 2003 until present via the self-reports of all participants who have taken part in the rehabilitation programme. Data is stored in the Friskgaarden database (FDB) for the purpose of research, and this database has been approved by the Norwegian Data Protection Authority. All participants provided written consent. For those who met the study inclusion criteria, self-reporting measures were linked on an individual level to different national health registries integrated into Statistic Norway’s (SSB) database (relating to DP, education, marital and family status) by using the 11-digit identity numbers unique to all Norwegian citizens. The register data cover the period of 2003–2010. The present study has been approved by the Regional Committees for Medical and Health Research Ethics (REC) in Mid-Norway. Disability Pension The outcome variable data defined as a permanent DP C50 % received after the start date of rehabilitation programme was collected up to December 2010 from the NAV-registries (SSB’s event-database) . The first date of DP following rehabilitation was used in order to prevent a possible mixing of effects from being in a disability process at baseline. Within the Norwegian welfare scheme, a DP is intended to secure the income for individuals who have had their work ability permanently reduced by C50 % due to an illness, disease, injury, or disability accepted as a medical condition. To be entitled to a DP, the applicant must have been a member of the National Insurance Scheme for at least 3 years, be between 18 and 67 years old, and have undergone appropriate medical treatment and work-oriented measures to access work to a sufficient degree. The capacity to perform work must be permanently impaired by at least half, and the illness or disability must be the main cause of the impaired earning ability. DP in Norway is a government responsibility, and all entitlements are accurately documented in the NAV registries .
variable was divided into three categories: primary or none, secondary, and college/university. The education level serves as a proxy for SES and is found to be an excellent predictor of SES in mid-life . The employment status, obtained from the FDB, of the study participants (based on hours worked), was reclassified into the following categories: unemployed, B50 % work, and [50 % work. Psychosocial Factors [19, 21] Psychosocial risk factors, obtained from SSB’s event database , included the categorical variables: separated or divorced (vs. married or unmarried) and single parent (vs. couples with children, couples without children, or singles). Teenage parenthood, defined as having a child before the age of 20, was dichotomous. Measures of anxiety, depression and pain were obtained from FDB. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS) . HADS consists of 14 items divided into two subscales for anxiety and depression. Each item is rated from 0 (not present) to 3 (maximum), and the total score range on the two sub-scales is thus 0–21. Anxiety and depressive disorders are indicated at scores C8 for both subscales, giving sensitivities and specificities of 0.80 . HADS has been validated in a range of healthcare settings and age groups . The tests of internal consistency and test-retest reliability of the scale have been found to be satisfactory . The Visual Analogue Scale (VAS) was used to assess pain measurements for ‘‘worst imaginable pain’’ and ‘‘how troublesome you experience the pain’’. The VAS is a 100 mm line with two end-points representing the continuum of the symptom to be rated . The VAS appears to be a good way to assess the intensity of pain and complaints relating to the subjective experience of pain. Measuring pain with the VAS has been found to correlate significantly with other pain measurement scales . Health-behaviour Factors [15, 22] Health-behaviour risk factors, obtained from FDB, were measured by two dichotomous variables: high medical consumption (the consumption of medication weekly or more often vs. less than weekly or never) and high alcohol consumption (drinking alcohol weekly or more often vs. less than weekly or never).
Explanatory Variables Statistical Analysis Citations to validation studies and to theoretical contexts for the explanatory variables are given below. In the analysis these variables were classified as follows: Socio-economic Factors [10, 13, 16, 17] Information on educational levels was obtained from the National Education Database (NUDB) administrated by SSB. This
The data-linking procedures were conducted using the IBM Corp., released 2011. IBM SPSS Statistics for MAC, (Version 20.0) whereas all statistical analyses were done by using StataCorp, released 2013. STATA MP for Mac (version 13). The data analyses were performed in three steps. First, descriptive analyses of means and percentages
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were calculated, and the significance of the difference between the rehabilitation group and workers was tested by independent sample t tests and Chi squared tests, respectively. Initial socio-demographical, psychosocial and health-behaviour risk factors were included as explanatory variables. Second, unadjusted odds ratios (OR) were computed using the binary logistic regression model, with the entitlement of DP as the response variable. All explanatory variables from the descriptive analysis were tested in a bivariate logistic regression model before being entered into the full model. In the third step, only significant predictors from the bivariate analysis were added to the final multivariate logistic regression model.
for college/university-educated individuals (OR 0.35, CI 0.14–0.87), whereas the effect of secondary education disappears (no longer significant). The effect of age (OR increase per year 1.09, CI 1.03–1.16) is similar to Model 1. The risk for DP seemed to decrease with an increasing degree of work. Individuals who had up to 50 % work (OR 0.32, CI 0.17–0.61) and C50 % work (OR 0.12, CI 0.06–0.25) had a lower risk for DP compared to unemployed individuals. In the full model (Table 2, Model 3), the effect of education was no longer significant, whereas the effect of work was even stronger (OR for up to 50 %: 0.145 vs. OR for 51–100 %: 0.099). Teenage parents (OR 3.0, CI 1.02–8.83) and single individuals (OR 3.74, CI 1.28–10.95) had an increased risk for early disability retirement.
Results Characteristics of the Study Population
A total of 937 individuals aged 18–40 years attended the vocational rehabilitation programme during the period 2003–2009. Nine persons were excluded from the analysis because of negative follow-up time (i.e. participants who were recipients of disability benefits previous to the rehabilitation), leaving 928 participants for follow-up. A total of 60 individuals were granted DP in the follow-up period. Descriptive statistics of the rehabilitation group (n = 928) and workers (n = 65) are presented in Table 1. The rehabilitation group showed a significantly (p \ 0.001) lower education level, was more often unemployed or employed part-time, and reported a higher frequent consumption of medication (p \ 0.05) compared to the workers. The rehabilitation group included more teenage parents and reported significantly less alcohol consumption than workers. The rehabilitation group also reported significantly (p \ 0.001) more anxiety and depression, as well as higher pain scores, compared to the workers.
In accordance with Rose , the present study demonstrated that being granted a DP following vocational rehabilitation among young adults of less than 40 years was associated with several socio-demographical, psychosocial and health-behaviour factors. We found substantial differences between young employees in ordinary work and those who participated in vocational rehabilitation in terms of education, employment, anxiety and depression scores, reported pain and medical consumption, as well as in the incidence of teenage parenthood. A low education level, unemployment, being single or being a teenage parent strongly influenced the risk for receiving DP following the rehabilitation period. The level of education has previously been found to affect the risk for early disability retirements [16, 17]. Accordingly, we found that a high education level was significant in protecting DP following vocational rehabilitation among young adults. In Norway, the drop-out risk for secondary education is 0.3 . This is problematic due to the fact that an upper secondary education is assumed to be the minimum necessary education and occupies a central role in the determination of individual standards of living . Several studies have indicated that people’s health and happiness, their economic security, opportunities and SES are each affected by the level of education [9, 11, 36, 37]. In addition, there is a growing consensus that upper secondary education completion is essential to success in the modern labour market . One reason for this might be that education provides knowledge about how society is structured and may contribute to an understanding of how to fill different roles in society and cope with the challenges life brings. In line with previous studies [3, 11], our results demonstrated that being employed, fullor part-time, highly protected early DP following
Associations Between Disability Pensions and Predictor Variables Among the Rehabilitation Group Table 1 shows the crude OR at follow-up for being granted a DP [50 % according to socio-demography, psychosocial condition and health behaviours. Significant predictors from the bivariate analysis were added to the full model. Starting from baseline rehabilitation, the effects of age, education level, work status, family type and teenage parenthood on the risk for DP following the vocational rehabilitation programme are presented in Table 2. Model 1 shows that an increasing education level decreases the risk, whereas increasing age increases the risk for DP. Adding work status to the model (Model 2) results in a lower OR
J Occup Rehabil Table 1 Distribution at baseline in socio-demographic, psychosocial and health behaviour factors among the rehabilitation group (N = 928) and workers (N = 65) as well as crude odds ratios (OR) at follow up for being granted a disability pension [50 % according to the characteristics of the rehabilitation group
Rehabilitation group (n = 928)
Workers (n = 65)
Crude OR (95 % CI)
Primary or none
Until 50 % work
Over 50 % work Marital status (%)
Age (mean) Disability pension [50 % (%) Gender (%female)
Work status (%)
Family type (%) Couple with children Couple without children
Teenage parenthood (%)
Alcohol consumption (% weekly)
Medical consumption (% weekly)
Pain trouble (mean)
HADS The Hospital Anxiety and Depression Scale a
Significant difference (p value B 0.05) between non-workers and workers tested by Chi quadrat test
Significant mean difference (p value B 0.05) between non-workers and workers tested by independent sample t test
rehabilitation. In modern western societies, employment is a central feature of daily life and the main source of financial independence, status, identity, and social participation. However, during the last decade the nature of work has undergone major change in terms of greater mental and emotional demands as compared with previous decades. In relation to that, Krokstad et al.  and Leinonen et al.  found that the effects of education and social class on disability retirement were stronger in younger age groups, which points to great problems for young people in the labour market with less education. These findings support the thinking that preventive efforts should emphasize completion of secondary and higher education, as well as ensure employment for both part- and full-time work for young adults at high risk for early work retirement. Furthermore, vocational rehabilitation aimed at this group should consider finding suitable jobs and internships that
correspond to the participants’ own function, skills and interests. Unexpectedly, and in contrast to previous research [1, 2, 4], anxiety and depression at the baseline of rehabilitation were not found to be associated with future DP. However, the fact that there was a generally high level of mental health issues among the rehabilitation group should not be forgotten. Both anxiety and depression scores were significantly higher among the rehabilitation group as compared to the workers’ and to those found in the general population , indicating mental health-related employment inequalities as reported by the OECD . Social context and social relations, such as living with a partner and having children, can protect against future DP [3, 11, 23]. However, Gustafsson et al.  and Floderus et al.  found that parenthood contributed to an increased risk of DP in the long term among young women,
J Occup Rehabil Table 2 Odds ratio (OR) relating to increased incidence of disability pension for people 18–40 years of age on entry into the vocational rehabilitation program when change in age and education level (model 1), model 1 ? work status (model 2) and model 2 ? family type and teenage childbearing (model 3)
95 % CI
95 % CI
95 % CI
Age Age at baseline
Education Primary or none
Work status Unemployed
0–50 % work
50–100 % work
Teenage parenthood Family type
Couple with children
Couple no children
CI confidence interval *** p \ 0.01; ** p \ 0.05; * p \ 0.1
especially among single mothers. In the present study we found that the risk for early DP was almost three times higher in individuals living alone as compared to couples with children. In accordance with that, Gustafsson et al.  found a higher risk of DP among single women aged 31–40 years. However, in contrast to Gustafsson et al.  and Floderus et al. , we did not find any association between early DP and being a single parent. Teenage parenthood was highly associated with an increased risk for early DP, which is consistent with previous studies . Becoming a teenage parent may have long-term socioeconomic consequences in terms of a loss of education, which may lead to fewer opportunities in the work life. There is a need for more longitudinal studies, with separate analysis of family status, including working status among working-aged women and men, in order to evaluate the hypothesis of a ‘‘double burden’’ effect (work, partnership, and children) as reported in Gustafsson et al. . The results from this study did not support our hypothesis that health-behaviour risk factors, measured as drug and alcohol consumption, would be positively associated with early DP among young adults in vocational rehabilitation. In contrast, Mansson et al.  found that the use of analgesics and hypnotics are positively related to poor self-rated health and predicted DP in middle-aged men within an 11-year follow-up. However, in line with Berkman and Kawachi’s assumption that much behaviour is socially patterned , we found significant differences in medical consumption and alcohol use between the
rehabilitation group and the working population. Considering that Individuals in rehabilitation initially have a greater risk of early disability retirement compared to the general population, there may be other factors that affect future DP to a greater extent than drug and alcohol consumption. Additionally, our results showed that the rehabilitation group had a significantly lower alcohol use as compared to the workers, which was unexpected and in contrast to Berkman et al. . In this context, a significant question is whether self-reports provide reliable and valid measures of alcohol and medical use. Thus, the self-reported medication use in clinical settings should be validated against the dispensing of prescribed medication. In summary, this study shows the complexity of the processes leading to early disability among young adults in vocational rehabilitation by uncovering several non-medical factors that influence this process. Health and health behaviour is not randomly distributed, but socially patterned, particularly showing a negative effect on people with low SES [6, 7]. Thus, it is important to examine possible causal pathways, including how social conditions affect DP through behaviours known to’ be related to DP risk. In other words, to investigate the cause of the risk factors associated with early DP. In the present study we have found that a low educational level, being alone, teenage parenthood and a weak connection to working life are risk factors for early DP among young adults in vocational rehabilitation. One possible causal pathway might be that social circumstances affect the disability
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process through the temporal order of life events. Teenage parenthood may produce an accumulation of life disadvantages, from loss of education to socioeconomic hardship, including a weak connection to work life . In addition to education being a key factor for work participation , a large amount of research indicate that educated people tend to make better choices about factors that affect their health and quality of life, they are more actively engaged in the community and have, in general, more opportunities both in civic and work life than those who are less educated . Furthermore, social inequalities in types of work and access to the labour market have been reported in numerous studies, showing that high-SES individuals generally have more flexible jobs. Employment characteristics are closely linked to SES and play an important role for health and wellbeing in adult life . Both low education levels and non-work participation are found to be associated with some form of health-damaging behaviour, which may play an important role in contributing to the social distribution of DP’s. However, the link is not clear and more research is necessary to explore the mechanism behind the process of educational decision-making and the link with early disability retirement.
Methodological Considerations The major strength of this study is that we combine selfreported data in a rehabilitation setting with national register data containing several predictors and the outcome variable DP. Our data from national registers enabled us to track the same individuals over a long period of time. By excluding participants who were granted a DP prior to the rehabilitation period, the possible mixed effect of a disability process in progress at baseline was prevented. Several limitations are apparent in our study. One shortcoming is that several exposure variables were self-reported, introducing a risk of misclassification bias due to participants responding incorrectly, whether consciously or unconsciously. In the present study one potential source of bias may be exaggeration or understatement, meaning that the outcomes are reported as more significant than they actually are. One possible reason for this would be that the rehabilitation centres provide the assessment of function and work capacity required to maintain the right to financial support in the form of social security benefits (including the basis for application of DP). Furthermore, selection bias is a potential problem in the present study as the rehabilitation group is just a small sub-population of all Norwegians in vocational rehabilitation. In addition, there may be several unobserved confounding variables which affect both the explanatory variables and disability retirement, such as factors related to genetics, personality, and
life-style, as well as other factors related to the processes leading to early DP not fully captured by the data. Despite these shortcomings, the study highlights important perspectives in a real clinical setting that should be taken into account in the rehabilitation of chronic musculoskeletal pain, and in primary prevention at population-level among young adults at high risk for early disability retirement. The present study also raises interesting perspectives in relation to the influence of work and social relations on young individuals in vocational rehabilitation. These are perspectives that should be taken into account in rehabilitation settings.
Interpretations and Conclusion Our results suggest that poor social relations (being alone), teenage parenthood and a weak connection to working life are all factors that, after adjusting for education levels, contribute to an increased risk of DP in young adults. Being unemployed was the strongest predictor of early DP, highlighting the importance of maintaining employment and finding suitable internships for young adults during the vocational rehabilitation period. Furthermore, social and family relations were also important predictors of DP, reflecting the complexity and need for support in several areas of life in the vocational rehabilitation of young adults. The results of this study offer insights on young DP users that should be considered in order to design goaloriented interventions aimed at individuals particularly at risk for an early work-life exit. Acknowledgments The authors would like to thank the participants of the rehabilitation programme for their permission to use personal information for research purposes. Friskga˚rden, located in NordTrøndelag County, has since 1995 developed a multidisciplinary rehabilitation model for individuals at sick leave with complex disease conditions. We would also like to thank two anonymous reviewers for their helpful comments on an earlier draft of this paper. Conflict of interest of interest.
The authors declare that they have no conflict
Informed consent All procedures followed were in accordance with the ethical standards of the Helsinki Declaration of 1975, as revised in 2000. The study was approved by the Regional Committees for Medical and Health Research Ethics (REC) in Mid-Norway and informed consent was obtained from all participants included in the study.
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