Article Text

Original research
Associations between the Abilitator, a self-reported measurement tool of work ability and functioning, and national register-based indicators of health and employment
  1. Johanna Kausto,
  2. Kia Gluschkoff,
  3. Joonas Poutanen,
  4. Miia Wikström,
  5. Matti Joensuu
  1. Finnish Institute of Occupational Health, Helsinki, Finland
  1. Correspondence to Dr Johanna Kausto; johanna.kausto{at}ttl.fi

Abstract

Objectives The Abilitator is a recently developed self-reported measurement tool for work ability and functioning of people in a weak labour market position. The aim of this study was to describe how self-reported information gathered with the Abilitator corresponds to information drawn from national registers.

Design, setting and participants Participants (n=669, mean age 44 years, 55% women) took part in the Work Ability Programme (2020–2023) that provided services for unemployed people with reduced work ability. They filled in the Abilitator questionnaire at the start of the service. Register-based data on participants’ health, income and received benefits was drawn from national registers. We evaluated how the different types of indicators concurred.

Results Statistically significant correlations (from weak to moderate) were found between different domains of the Abilitator and register-based data. Also, participants’ health status (information on mental health or musculoskeletal disorders) was displayed coherently in the results of the Abilitator. Overall, diagnosed mental health disorders distinguished participants’ Abilitator responses more strongly than diagnosed musculoskeletal disorders.

Conclusions These findings provide further evidence on the applicability of the Abilitator as an instrument to evaluate work ability and functioning of people outside the work force.

  • REHABILITATION MEDICINE
  • PUBLIC HEALTH
  • MENTAL HEALTH
  • Psychometrics
  • Social Interaction
  • SOCIAL MEDICINE
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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Strengths include applying a multidimensional patient-reported outcome measure (the Abilitator) to evaluate work ability and functioning of those outside the work force.

  • Using national reliable register-based data linked with self-reported data collected with the Abilitator was a strength in this study, as well.

  • A limited number of participants.

  • Limited knowledge on the generasilibility of the results to population level.

Introduction

Increasing labour market participation of those in working age is a common goal shared between countries with ageing population. In recent years, employment has indeed increased in many countries. However, in a Nordic comparison, both unemployment and inactivity rates are high in Finland.1 2 It has been found in Finland that a fifth of those in working age reported impaired work ability.3 4 A fifth of those unemployed needed rehabilitation before returning to work and a fourth of them did not have prospects for returning to the open labour market.5 As was claimed in the previous programme of the Finnish government,6 it is essential to increase the labour market participation of people with partial work ability and of those with poor employment prospects.

Sustainable work is a concept used to describe inclusive, meaningful and healthy work life that is required to keep as many as possible attached to work. Making work more sustainable, could encourage working until old ages but also increase the labour market integration of people with partial work ability and poor employment prospects.7 8 Effective measures are needed to promote the employment of the latter group of people and a broad array of services is being offered in many countries, also in Finland. Reliable data on the clients’ needs and changes during the services are essential for planning the allocation of resources. The use of patient-reported outcomes (PROs) has been promoted for this purpose.9

PROs can be defined as measurements of the patients’ or service clients’ self-reported health, functioning, well-being and health-related quality of life. Patient-reported outcome measures (PROMs) are standardised, reliable and validated instruments designed for creating PROs.9–14 The Abilitator is a multidimensional PROM developed to evaluate work ability and functioning of those outside the work force.10 In this study work ability and functioning was defined and evaluated in accordance with rehabilitation studies as a multidimensional enablement process emphasising the role of contextual factors in participation to work.15 The Abilitator was used in the Finnish Work Ability Programme Evaluation Study (2020–2023)16 (online supplemental files 1 and 2), conducted by the Finnish Institute of Occupational Health and Finnish Institute for Health and Welfare, for the evaluation of work ability and functioning of the programme participants.

Psychometric properties of the Abilitator have so far been evaluated in three studies showing adequate reliability and validity.9 10 17 The aim of this study was to explore how self-reported work ability and functioning data, gathered with the Abilitator, corresponded to reliable, register-based information drawn from national registers. First, associations between the Abilitator variables and register indicators were explored. Second, we tested whether participants’ health status (register-based diagnosis on mental health disorders (MHDs) or musculoskeletal disorders (MSDs) was displayed coherently in the results of the Abilitator. It was hypothesised that register-based indicators would be reflected in the corresponding contents of the self-reported information in the Abilitator measure.

Methods

Study setting

Finnish Government’s Work Ability Programme (2020−2023) sought solutions to the acknowledged problems in the employment of people with partial work ability.18 The programme included two sets of measures that were implemented by 22 government grant projects across Finland in 2020−2022. The sets of measures were the development of work ability support services in the social and health centres and methods of supported employment. This study is a part of the Finnish Work Ability Programme Evaluation Study (2020–2023) conducted by the Finnish Institute of Occupational Health and Finnish Institute for Health and Welfare.16

Participants

The study sample consists of participants who took part in the Finnish Work Ability Programme evaluation study (2021−2022). The participants answered the Abilitator questionnaire during 2021−2022 while entering the Work Ability Programme services (n=1535). Participation was voluntary and written informed consent was obtained for the gathering of register-based data and linking it to the self-report data (n=669).

Data and measures

Data drawn from national registers of the Statistics Finland, Social Insurance Institution of Finland, Finnish Centre for Pensions, and Finnish Institute for Health and Welfare were linked with the self-reported data from the Abilitator using unique social security numbers. Such numbers are assigned to each citizen of Finland at birth and for migrants when they get a residence permit, and they are common to all administrative registers, enabling extensive record linkages.19

Self-report data

The Abilitator comprises the following domains: Personal information (eg, age, gender), Well-being (eg, general functioning, perceived work ability), Inclusion (social functioning and social interaction), Mind (mental functioning), Everyday life (coping with everyday activities), Skills (eg, cognitive functioning, competence), Body (physical functioning), Background information (eg, educational background) and Work and the future (eg, employment situation, desired changes). Each domain consists of 4–14 questions totalling to 84 items. Most items are measured with a 1–5 rating20 (online supplemental files 1 and 2).

For example, perceived work ability (in the domain of Well-being) was measured with a question: ‘Let’s assume that your work ability would receive a score of 10 points at its best. What score would you give your current work ability? (0 means that you are currently unable to do any work)’ and answered with a scale ranging from 0 (completely unable to work) to 10 (work ability at its best). Inclusion was measured for example, with propositions: ‘I get help when I need it’, ‘I am needed by others’, ‘I am allowed to express my opinions and they are taken into account’ and ‘I feel part of society’. These items were answered with a scale from 1 (completely disagree) to 5 (completely agree).

The domain of Mind included for example, the following propositions: ‘I’ve been feeling optimistic about the future’, ‘I’ve been able to make up my own mind about things’ and ‘I’ve taken pleasure in things that are important to me’. These propositions were answered with a scale ranging from 1 (never) to 5 (all the time). In the domain Everyday life, the respondent was asked: ‘How well do you cope with the following everyday tasks: Housework, shopping, using public services, using the internet, searching for information, taking care of personal finances, using health services, etc’. The questions were answered with a scale from 1 (I am unable to cope) to 5 (I cope well). The domain of Skills included for example, the following questions: ‘How well do the following statements reflect how you feel about the future and your skills?’: ‘I feel positive about the future’, ‘I am ready to make an effort and take action in order to make my dreams come true’ and ‘I have skills that I can use in work life’. These items were answered with a scale from 1 (completely disagree) to 5 (completely agree).

In the domain of Body, the respondents were asked for example, ‘Do you suffer from one or more prolonged physical or psychological illness, symptom or injury? By prolonged we mean lasting at least 6 months and they answered no or yes. If they answered "yes", they were asked to ‘Assess how much of an impediment these illnesses, symptoms or injuries are (in l eisure-time activities, housework, work or possible work and personal relationships)’. Choose the number (from 0 (no impediment) to 10 (worst possible impediment)) that best describes the extent of this impediment.

In the domain of Work and the future, the respondents were asked for example, ‘How difficult do the following make it for you to participate in work life—lack of job opportunities, commuting difficulties, lack of training and skills, diminished work motivation or desire to work, problems connected to health or functional capacity, personal life situation, substance dependence and other addictions, criminal or drugs record, and financial situation’. The items were answered with a scale from 1 (extremely difficult) to 5 (not difficult at all).

Register-based data

Data on basic sociodemographics (year of birth, sex, education (classified as low (primary education or lower secondary education), intermediate (upper secondary or post-secondary non-tertiary education), and high (short-cycle tertiary or higher education)), region (ie, area of residence), and mean annual gross income in 2020) were drawn from the registers of Statistics Finland. The number of healthcare visits was drawn from a national register ‘The Care Register for Health Care’ managed by Finnish Institute for Health and Welfare. This register contains comprehensive information on patients discharged from inpatient care, patients in inpatient care in health centres and public and private hospitals, day surgeries, and specialised outpatient care for all residents in Finland. We calculated the total number of all healthcare visits (both inpatient and outpatient) in 2020–2022. We also drew outpatient visits in 2020–2022 separately in MHDs and in MSDs. This information was used in forming groups of participants with a register-based diagnosis in .

The number of days (before the end of 2021) that the client had no information in the earnings and accrual register (ie, the number of days the client had not received wages or social benefits for which pension accrues), indicating time spent outside the workforce, was obtained from Finnish Centre for Pensions. The resulting measure ‘days outside the workforce’ represented thus the number of days that had passed between the last period of employment (or a period of pension-accruing social benefits) and the end of 2021.

The number of months receiving income support during 2020–2022 was drawn from the registers of the Social Insurance Institution of Finland.

Statistical analyses

We first derived the descriptive statistics and then calculated bivariate correlations between the domains or items of the Abilitator and different register-based variables. Correlations were assessed based on their strength of association: weak (0.1≤r<0.3), moderate (0.3≤r<0.5) or strong (≥0.5). Using Welch two-sample t-test, we then compared the results of the Abilitator among those with MHDs (ICD-10 F-codes) or MSDs (ICD-10 M-codes) with the results of those who did not have outpatient visits related to MHDs or MSDs. For differences in means, we also calculated standardised differences in means (Cohen’s d)21 and interpreted effect sizes as weak (0.2≤d<0.5), moderate (0.5≤d<0.8) or strong (d≥0.8).

Patient and public involvement

No patients involved.

Results

Those who gave their consent for the linking of register and self-report data were somewhat older, had somewhat lower work ability, and somewhat longer duration of unemployment. Overall, these differences were very small. Register-based descriptive statistics of the study population are presented in table 1. From the total of 669 participants, 55% were women. The mean age of participants was 44 years. The majority had a secondary education and they most often resided in Western Finland. On average, the participants had been outside the workforce for over four years before the end of year 2021.

Table 1

Register-based descriptive statistics of the study population (n=669)

Data gathered with the Abilitator questionnaire is shown in table 2. The Abilitator scores indicated that respondents had challenges related to health and well-being, which was reflected, for example, in reduced Mind and Body summary scores. They had the highest scores in coping best in Everyday life. Problems connected to health or functional capacity and lack of job opportunities were seen as the largest barriers to participation in work life.

Table 2

Data gathered with the Abilitator questionnaire (n=669)

Figure 1 shows the correlations between the domains of the Abilitator and the register-based data. All domains of the Abilitator, except for the domain measuring employability and duration of unemployment, correlated negatively (Pearson r=−0.14 to −0.22) with the number of healthcare visits in 2020–2022. All domains of the Abilitator correlated (r=−0.16 to 0.23) with the number of income support months in 2020–2022.

Figure 1

Correlation (Pearson r) between the Abilitator and different register-based indicators. Statistically significant correlations are shown in black.

Figure 2 shows the correlations between the Abilitator variables for self-reported barriers to employment (scale 1=extremely difficult to 5=not difficult at all) and register-based data. Self-reported health-related problems as barriers to employment in the Abilitator correlated (r=−0.17 to −0.24) with the number of healthcare visits, diagnosis of mental health or musculoskeletal disorders and the number of months on income support. Troubles related to commuting were related for example, with a diagnosis on MSDs (r=−0.19). Self-reported substance abuse or addiction as a barrier to employment was related to the number of healthcare visits, days unemployed or months of received income support (r=−0.14 to −0.17). Self-reported lack of work possibilities was not related to any of the register-based indicators. Overall, the correlations between the Abilitator and register data were weak to moderate in size.

Figure 2

Correlation (Pearson r) between the Abilitator (barriers to employment) and different register-based indicators. Statistically significant correlations are shown in black.

We tested how register-based information on diagnosed MHDs or MSDs was reflected in participants’ Abilitator responses (table 3). In both diagnostic groups, those with a diagnosis reported lower scores than those without a diagnosis in following domains of the Abilitator: Inclusion, Mind, Everyday life, Skills and Body. Diagnosed MHDs distinguished participants’ Abilitator responses more strongly (Cohen’s d for the difference ≥0.58 indicating moderate or strong effect sizes) than diagnosed MSDs (except for the summary scale ‘Body’).

Table 3

Mental health disorders (MHDs) and musculoskeletal disorders (MSDs), summary scales of the Abilitator mean (SD), Welch two sample t-test and Cohen’s d* for the difference between participant groups

Discussion

We found that self-reported data, gathered with the Abilitator questionnaire, concurred well with register-based data from reliable national registers. Correlations ranged from weak to moderate. Also, register-based information on diagnosed MHDs (ICD-10 F-codes) or MSDs (ICD-10 M-codes) was reflected reasonably well in participants’ Abilitator responses. Diagnosed mental health problems distinguished participants’ Abilitator responses more strongly than diagnosed musculoskeletal disorders (except for the summary scale‘Body’). To the extent that construct validity of a measure is defined as the degree to which the scores of an instrument are consistent with hypotheses (for instance, regarding relationships to scores of other sources, or differences between relevant groups),22 the results of this study suggest an acceptable construct validity of the Abilitator. Our findings add to previous studies9 10 17 which have shown the content and concurrent validity, intrarater test–retest reliability and internal consistency of the Abilitator as a PROM.

The strengths of our study include using national reliable register-based data linked with self-reported data collected with the Abilitator. So far, studies applying multidimensional PROMs to evaluate work ability and functioning of those outside the work force are scarce. Altogether, a recent review and meta-analysis found insufficient evidence on the effects of PROMs on the outcomes and management of MHDs.23 However, this probably is due to relatively low quality of existing studies. The number of participants was limited in our study. There were some missing data in self-reported data, but considering our target group, the response rate was good. One item-measures and their use as continuous variables can be seen as a limitation in this study. In the future, we will investigate the predictive value for employment outcomes of the Abilitator.

Our sample was derived from participants of a service for unemployed individuals with limitations in their work ability. This corresponds to the target group of the Abilitator questionnaire. However, there may be factors that influence the selection into these services and thereby to the sample which may introduce bias. Because we only had register-based data for those individuals who chose to participate in the study we could not compare their characteristics to the total eligible population. There was not any strong indication of selection of those participants who gave their consent for the use of register data.

Sustainability of work and work life is a suitable theoretical concept and a larger framework for positioning the Abilitator. The Abilitator is among the very few measures of work ability and functioning addressing those outside the workforce or otherwise in a weak labour market position. These measures are needed for supporting these clients’ different transitions between jobs, between employment and unemployment, or transitions back to work after longer periods of illness and work disability.24 Besides increasing the number of work hours, increasing diversity of working people and work life can be considered as important source for and result of sustainability. A work system that is formed by various kind of people and diverse resources is argued to be more sustainable than a uniform work system relying only on a limited set of resources.25 Another perspective to the sustainability of work life is social justice.24 People differ a lot in their working conditions, resources and career paths. Expecting workwise the same from everybody is not reasonable. Flexible rules of social protection and tailored services with valid measures are needed.25

Conclusions

This study provides further evidence on the applicability of the Abilitator as an instrument to evaluate work ability and functioning of people outside the work force. Using these measures to support clients’ diverse work paths and variability in work participation is reasoned in the framework of sustainability of work life.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and 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. Ethical approval was obtained from the ethical boards of the Finnish Institute of Occupational Health and Finnish Institute for Health and Welfare in 2021. Participants gave informed consent to participate in the study before taking part.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

  • Supplementary Data

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Footnotes

  • Twitter @johanna_kausto

  • Contributors Conceptualisation and methodology: JK, KG, JP, MJ. Writing–original draft preparation: JK. Writing–review and editing: JK, JP, KG, MJ, MW. Project administration: MJ. Guarantor: MJ. All authors have read and agreed to the published version of the manuscript.

  • Funding This study and open access fees were funded as a part of actions by the Finnish Ministry of Social Affairs and Health as a part of Finnish Government’s Work Ability Programme. Open access fees were funded by the Finnish Institute of Occupational Health.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.