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RESEARCH ARTICLE
Do individual and work-related factors
differentiate work participation trajectories
before and after vocational rehabilitation?
Taina Leinonen
1
*, Svetlana Solovieva
1
, Kirsti Husgafvel-Pursiainen
1
,
Mikko Laaksonen
2
, Eira Viikari-Juntura
1
1Finnish Institute of Occupational Health, Helsinki, Finland, 2Finnish Centre for Pensions, Helsinki, Finland
*taina.leinonen@ttl.fi
Abstract
Background
Understanding diverse labor market trajectories around vocational rehabilitation
provides important insight into potential effectiveness of rehabilitation efforts. We examined
factors associated with work participation trajectories before and after vocational
rehabilitation.
Methods
Using nationwide Finnish register data of 7180 vocational rehabilitees, we constructed latent
trajectory groups of work participation two years before and two years after their rehabilita-
tion episode starting in 2008–2010. We plotted changes in labor market statuses in these
groups and examined other associated factors using multinomial logistic regression.
Results
We identified four trajectories based on work participation levels before and after vocational
rehabilitation. The “High–Resumed” group (35.6%) typically returned to full duties. The
“High–to–Negligible” group (20.7%) typically transitioned to full disability retirement or
unemployment. Among the “Medium–Resumed” (25.5%) and “Longstanding Negligible”
(18.3%) groups, work disability and unemployment were common before rehabilitation, but
afterwards those assigned to the former group often returned to full or partial duties. Overall,
older age, male gender, living in areas with lower employment rates, having lower educa-
tion, being employed in the private sector, and having mental diagnoses were associated
with the other three trajectories than the most favorable “High-Resumed” trajectory. Further-
more, certain industrial sectors, job exposures, and less common diagnoses further sepa-
rated specific trajectories.
Conclusions
Work participation trajectories around vocational rehabilitation are diverse, only partly
dependent on initial levels of work participation, and determined by various individual and
PLOS ONE | https://doi.org/10.1371/journal.pone.0212498 February 21, 2019 1 / 19
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OPEN ACCESS
Citation: Leinonen T, Solovieva S, Husgafvel-
Pursiainen K, Laaksonen M, Viikari-Juntura E
(2019) Do individual and work-related factors
differentiate work participation trajectories before
and after vocational rehabilitation? PLoS ONE
14(2): e0212498. https://doi.org/10.1371/journal.
pone.0212498
Editor: Tracey Weiland, University of Melbourne,
AUSTRALIA
Received: June 4, 2018
Accepted: February 4, 2019
Published: February 21, 2019
Copyright: ©2019 Leinonen et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: We used third party
register data from the Social Insurance Institution
of Finland, the Finnish Centre for Pensions, and
Statistics Finland. The data were linked together
and pseudonymized by Statistics Finland. The
authors do not have the permission to share this
data. Due to data protection regulations of the
administrative sources providing the data, the data
can only be accessed by individual researchers
who have obtained permission from each of the
used data sources. The authors obtained
work-related factors. Future nationwide studies should assess the effectiveness of voca-
tional rehabilitation taking into consideration both individual and work-related factors.
Introduction
Labor market outcomes after vocational rehabilitation may depend on various characteristics
of the rehabilitee such as labor market history, the nature of work disability, and sociodemo-
graphic factors. More favorable employment outcomes have generally been reported for indi-
viduals who are younger, have a higher socioeconomic position, have more previous
employment, and have shorter length of preceding disability, while variation by other factors
such as gender and disease groups remains unclear [1–10].
Assessment of labor market outcomes after vocational rehabilitation is complex, because
return to work may be perceived as a multiphase and multifaceted process rather than a single
event [11–13]. There is a large number of possible transitions between different labor market
statuses around rehabilitation [14–17] as well as potential variation between shorter- and lon-
ger-term outcomes [10,18,19]. Moreover, the close link between a rehabilitee’s preceding labor
market history and subsequent labor market outcomes may lead to biased conclusions of the
effects of vocational rehabilitation.
Investigating labor market trajectories over a lengthy period of time surrounding vocational
rehabilitation provides important insight into the factors associated with potential effective-
ness of rehabilitation efforts. While previous studies have examined changes between different
labor market statuses after vocational or other work-related rehabilitation [14–18], less is
known of labor market trajectories covering the period both before and after vocational reha-
bilitation [19]. Furthermore, predictors of such trajectories remain unclear.
We used nationally representative Finnish register data to identify latent trajectory groups
of work participation over a period of two years before and two years after an episode of voca-
tional rehabilitation. In order to find out which statuses the individuals in question occupied
while being out of work, we further examined changes in the receipt of different social security
benefits among the different trajectory groups. In addition, we examined factors associated
with being assigned to particular trajectory group of work participation around vocational
rehabilitation. More specifically, we aimed to answer the following research questions:
1. What kind of typical work participation patterns can be found around vocational
rehabilitation?
2. What kind of changes can be observed in statuses other than work, such as sickness
absence, disability retirement, and unemployment, around vocational rehabilitation among
groups following different work participation trajectories?
3. Are sociodemographic factors, prior work-related exposures, and characteristics of the
rehabilitation episode associated with particular work participation trajectories around
vocational rehabilitation?
Material and methods
Study design
We used a nationally representative 70% random sample of the working aged population living
in Finland on the last day of year 2007. The register-based data include information on
Work participation trajectories before and after vocational rehabilitation
PLOS ONE | https://doi.org/10.1371/journal.pone.0212498 February 21, 2019 2 / 19
permission to use the data through a standard
application process. Other interested researchers
have a possibility to access the data in the same
manner by filing applications to the Social
Insurance Institution of Finland (+358206341364,
tietopyynnot@kela.fi,http://www.kela.fi/web/en/
research-data-requests), the Finnish Centre for
Pensions (+3582941120, http://www.etk.fi/en/
statistics-2/statistics/producer-of-statistics/), and
Statistics Finland (+358295512564,
kirjaamo@tilastokeskus.fi,http://www.stat.fi/meta/
tietosuoja/kayttolupa_en.html).
Funding: This study was supported by the
Academy of Finland (project number 303534 to
Viikari-Juntura). The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
episodes of vocational rehabilitation, employment, unemployment, earnings-related retire-
ment, and other benefit receipt from the Finnish Centre for Pensions, on episodes of compen-
sated sickness absence and national pensions obtained from the Finnish Social Insurance
Institution, and on sociodemographic and work-related factors obtained from the Finnish
Longitudinal Employer–Employee Data (FLEED). For the purposes of this study, we utilized
information from calendar years 2006–2014.
Since 2004, vocational rehabilitation has been a statutory right in Finland. Eligibility to
vocational rehabilitation is based on evaluation of a threat of disability retirement within the
next few years due to a diagnosed illness or an injury as well as of the expectation that work
participation can be promoted and disability retirement postponed or prevented with voca-
tional rehabilitation. The system emphasizes early onset of rehabilitation in order to reach
these goals. Vocational rehabilitation in Finland is highly fragmented. Those who are attached
to working life with a sufficient amount of recent employment (sum of earnings in the previ-
ous five years approximately 35000 euros at 2017 level) are eligible for vocational rehabilitation
provided by the earnings-related pension scheme, while those who are outside working life
may receive vocational rehabilitation from the Social Insurance Institution of Finland or other
sources [20–22].
We studied only vocational rehabilitation that was provided by the earnings-related pen-
sion scheme, the rehabilitees therefore being relatively well attached to the labor market. This
does not mean that all rehabilitees came directly from employment. In 2016, 23% came to
vocational rehabilitation from retirement, typically after having received a temporarily granted
disability pension [23]. The main types of vocational rehabilitation provided by the earnings-
related pension scheme include training, work counselling, and work try-outs. Work try-outs
are the most prevalent type and often carried out at a person’s own workplace. Medical reha-
bilitation is not covered in the earnings-related pension scheme [21]. Our data did not include
information on medical rehabilitation or treatment.
We included individuals whose vocational rehabilitation episode began in 2008–2010 and
who were aged 25–59 at that time. Daily changes in work participation and other labor market
statuses were followed up over a period of two years before the begin date and two years after
the end date of vocational rehabilitation. This four-year measurement period of labor market
participation did not cover the time period in the middle that was spent in vocational rehabili-
tation. However, because our data on labor market participation was available until the end of
October 2014, and because we wanted to follow-up each study person over a full two-year
period after the termination of their rehabilitation episode, we could only examine rehabilita-
tion episodes that ended by October 2012, i.e. 22 months after the last episodes of year 2010
had begun. We therefore excluded individuals whose vocational rehabilitation episode lasted
more than 22 months (24.1%). The final study population consisted of 7180 individuals.
Work participation and other labor market statuses
Work participation trajectories was the outcome of main interest. We used information on
episodes of employment and of receiving social security benefits to calculate the monthly pro-
portion of time spent at work over the 24 months before and 24 months after vocational reha-
bilitation. We assumed that those who had an ongoing employment episode without receiving
any benefits that compensated for being out of work, such as sickness allowance, worked 100%
of the time; full-time work is very typical in Finland [24]. We also assumed that individuals
receiving a partial sickness allowance or a partial disability pension (together referred to as par-
tial work disability benefits) worked 50% of the time. In Finland, receipt of the partial sickness
allowance requires the person to work 40–60% of the time.
Work participation trajectories before and after vocational rehabilitation
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We further examined changes in six mutually exclusive labor market statuses over the two
years before and two years after vocational rehabilitation. By doing so, we could assess how
overall work participation was divided into full and partial duties as well as what were the prev-
alent statuses while being fully out of work. The statuses were 1) work (with full work duties),
2) partial work disability (with partial work duties), 3) full sickness absence, 4) unemployment,
5) full disability retirement (temporary or permanent), and 6) other (e.g. education, parental
leave, old-age retirement, or dead).
Covariates
We included sociodemographic factors (age, gender, region of residence, and education),
prior work-related exposures (industrial sector and various job exposures based on previously
developed job exposure matrices), and characteristics of the vocational rehabilitation episode
(employment sector, disease group, start year, and duration) as covariates. Age at the start of
rehabilitation was examined in groups 25–39, 40–49, and 50–59 years. Region of residence
and education were measured at the end of the year preceding the measurement period of
labor market participation. Region of residence consisted of categories 1) Southern, 2) West-
ern (including the Åland islands), 3) Eastern, and 4) Northern Finland. Education consisted of
categories 1) tertiary, 2) secondary, and 3) primary.
Industrial sector and occupational information for the job exposure matrices were also pri-
marily measured at the end of the year preceding the measurement period of labor market par-
ticipation. For those who were non-employed in that year, however, the information was
derived from the end of other years, available for industrial sector over a five-year period and
for occupation over a four-year period preceding the start year of vocational rehabilitation.
Priority was nevertheless given to deriving the information from the years preceding the mea-
surement period of labor market participation. Industrial sector and occupation could not be
identified for 160 and 285 individuals, respectively, because they were constantly non-
employed before rehabilitation. These individuals were excluded from the models including
industrial sector or job exposures.
Industrial sector was based on a classification by Statistics Finland. We examined the
following categories as dummy variables: 1) manufacturing, 2) trade (wholesale and retail
trade; repair of motor vehicles and motorcycles), 3) transportation and storage, 4) knowledge
work (information and communication; financial and insurance activities; real estate activities;
professional, scientific and technical activities), and 5) human health and social work
activities.
For occupation, we used a classification by Statistics Finland, based on the International
Standard Classification of Occupations (ISCO-88). Job exposures were then estimated for each
occupation with a gender-specific job exposure matrix (JEM), which was developed earlier in a
large population survey and described with more detail elsewhere [25,26]. Heavy physical
work, kneeling and squatting, as well as repetitive hand movements could receive values
between 0 and 100 (highest). For heavy physical work as well as kneeling and squatting, the fre-
quencies of exposure peaked at 0 and at a little above 40. We classified these exposures as 1)
none (0), 2) low (>0, <40), and 3) high (40). Repetitive hand movements had a more even
distribution and was used as a continuous variable. Job strain was based on the Karasek model
[27] including the categories 1) low strain (low job demands, high job control), 2) active job
(high job demands, high job control), 3) passive job (low job demands, low job control), and
4) high strain (high job demands, low job control). Monotonous work included the categories
1) no and 2) yes.
Work participation trajectories before and after vocational rehabilitation
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Employment sector that provided the vocational rehabilitation was classified as 1) private
and 2) public. In the national vocational rehabilitation scheme, the provider is selected based
on current or last employment.
The primary medical reason for vocational rehabilitation was classified according to the
tenth revision of the International Classification of Diseases (ICD-10). We examined the fol-
lowing disease groups as dummy variables: 1) musculoskeletal diseases (M00–M99), 2) mental
disorders (F00–F99), 3) neoplasms (C00–D48), 4) nervous diseases (G00–G99), 5) circulatory
diseases (I00–I99), and 6) injuries (injury, poisoning and certain other consequences of exter-
nal causes, S00–T98).
Duration of vocational rehabilitation was based on the total continuous duration and could
consist of various successive vocational rehabilitation efforts of different types. A large peak
was observed at the duration corresponding to around three months, and smaller peaks at the
duration corresponding to four, five, and six months. We categorized duration into 1) <3
months, 2) exactly 3 months (equaling 89–93 days), 3) >3 months, 6 months, and 4) >6
months.
Statistical analyses
We constructed work participation trajectories based on monthly measured work participa-
tion over two years before and two years after the episode of vocational rehabilitation. The
analysis time was assessed as a single four-year period, excluding the time spent in rehabilita-
tion. The work participation trajectories were obtained using a semiparametric group-based
modelling strategy by PROC TRAJ in SAS version 9.4 (SAS Institute, Cary, NC, USA). This
method was developed for analyzing longitudinal data, changes over time, and identifying dis-
tinct latent groups of subjects who tend to have a similar profile over time (trajectories)
[28,29]. The Bayesian information criterion (BIC) was considered when selecting the optimal
model, number of trajectories and their shape. With continuous data, the normal distribution
was used as the underlying statistical model.
After constructing the work participation trajectories, we plotted changes in the distribu-
tion of the six labor market statuses before and after vocational rehabilitation among the differ-
ent trajectory groups of work participation.
We then examined how the different covariates were associated with assignment to differ-
ent trajectory groups of work participation around vocational rehabilitation using multinomial
logistic regression analysis. We calculated relative risk ratios (RRR) and their 95% confidence
intervals.
Ethics statement
The study was fully register-based and applied identification numbers pseudonymized by Sta-
tistics Finland. Research using such data does not need to undergo review by an ethics com-
mittee according to Finnish legislation. The researchers analyzed the data stored by Statistics
Finland using a remote access system. All output extracted from the system was approved by
Statistics Finland to ensure compliance with data protection regulations.
Results
Over 40% of the rehabilitees were aged 50 or above and over 60% were women. Close to half of
the study population came to rehabilitation because of musculoskeletal diseases and over a
fourth because of mental disorders. Further characteristics of the rehabilitees are presented in
Table 1.
Work participation trajectories before and after vocational rehabilitation
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Table 1. Distribution of background characteristics among the vocational rehabilitees.
N % Range Mean
Age 25–59 46.2
25–39 1522 21.2
40–49 2737 38.1
50–59 2921 40.7
Gender
Women 4507 62.8
Men 2673 37.2
Region of residence
South 3239 45.1
West 1713 23.9
East 1092 15.2
North 1136 15.8
Education
Tertiary 1859 25.9
Secondary 3910 54.5
Primary 1411 19.7
Industrial sector
Manufacturing 1188 16.6
Trade 644 9.0
Transportation & storage 623 8.7
Knowledge work 597 8.3
Health & social work 1627 22.7
Other 2341 32.6
No industrial sector identified 160 2.2
Heavy physical work 0–100 37.1
None 517 7.2
Low 2906 40.5
High 3472 48.4
No occupation identified 285 4.0
Kneeling and squatting at work 0–96.7 26.9
None 805 11.2
Low 3821 53.2
High 2269 31.6
No occupation identified 285 4.0
Repetitive hand movements at work 0–100 45.3
Occupation identified for calculation 6895 96.0
No occupation identified 285 4.0
Job strain
Low strain 1119 15.6
Active job 709 9.9
Passive job 3289 45.8
High strain 1778 24.8
No occupation identified 285 4.0
Monotonous work
No 4658 64.9
Yes 2237 31.2
No occupation identified 285 4.0
(Continued )
Work participation trajectories before and after vocational rehabilitation
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Construction of the trajectory groups of work participation
Four trajectory groups of work participation around vocational rehabilitation were identified
(Fig 1). In the first group (35.6%), work participation was initially at a high level, declined par-
ticularly during a one-year period before vocational rehabilitation, and resumed close to its
initial level immediately after vocational rehabilitation (High–Resumed group). In the second
group (20.7%), work participation was initially at a high level, declined during a 1.5-year
period before vocational rehabilitation, increased only slightly and momentarily after voca-
tional rehabilitation, and then again declined reaching a negligible level by the end of the first
year after vocational rehabilitation (High–to–Negligible group). In the third group (25.5%),
work participation was initially at a medium level, declined particularly in the period 2–1 years
before vocational rehabilitation, and resumed its initial level or even slightly above immedi-
ately after vocational rehabilitation (Medium–Resumed group). In the fourth group (18.3%),
work participation was initially at a low level, declined reaching a negligible level already more
than one year before vocational rehabilitation, increased only very slightly and momentarily
after vocational rehabilitation, and then rapidly declined back to the negligible level (Long-
standing Negligible group).
Changes in labor market status among the trajectory groups
Among the High–Resumed trajectory group, the decrease in work participation before voca-
tional rehabilitation was mainly replaced by a corresponding increase in full sickness absence
(Fig 2a). The resumed high level of work participation after rehabilitation was mainly attrib-
uted to by return to full duties and to a relatively small extent by return to partial duties while
receiving partial disability benefits.
Table 1. (Continued)
N % Range Mean
Sector of rehabilitation
Private 4640 64.6
Public 2540 35.4
Disease group of rehabilitation
Musculoskeletal 3393 47.3
Mental 1942 27.1
Neoplasms 219 3.1
Nervous 350 4.9
Circulatory 290 4.0
Injuries 464 6.5
Other 522 7.3
Start year of rehabilitation
2008 2333 32.5
2009 2352 32.8
2010 2495 34.8
Duration of rehabilitation 0.1–22.0 5.2
<3 months 1474 20.5
3 months 2392 33.3
>3 months, 6 months 1826 25.4
>6 months 1488 20.7
Total 7180 100.0
https://doi.org/10.1371/journal.pone.0212498.t001
Work participation trajectories before and after vocational rehabilitation
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The decrease in work participation before vocational rehabilitation among the High–to–
Negligible group was also mainly replaced by an increase in full sickness absence, but also by
small increases in unemployment and full disability retirement (Fig 2b). After vocational reha-
bilitation, full disability retirement was the most common status followed by unemployment.
Partial work disability was not common among this group.
Among the Medium–Resumed group, full sickness absence was a common status particu-
larly in the period 2–0.5 years before vocational rehabilitation (Fig 2c). Partial work disability
somewhat increased before rehabilitation. Furthermore, the decrease in work participation
before vocational rehabilitation was countered by increases in full disability retirement and
unemployment. The resumed medium level of work participation after rehabilitation was
attributed to not only by return to full duties, but to a relatively large extent also by return to
partial duties while receiving partial disability benefits. Unemployment also remained rela-
tively common after rehabilitation.
The Longstanding Negligible group was mainly on full disability retirement both before
and after vocational rehabilitation (Fig 2d). Also sickness absence in the period 2–0.5 years
before rehabilitation and unemployment both before and after rehabilitation were common
statuses. Partial work disability was virtually nonexistent among this group.
Predictors of assignment to the trajectory groups
First, we assessed age- and gender-adjusted predictors of being assigned to the High–to–Negli-
gible, the Medium–Resumed, and the Longstanding Negligible trajectory groups of work par-
ticipation around vocational rehabilitation, compared to being assigned to the most favorable
group, i.e. the High–Resumed group (Table 2). Male gender, having less than tertiary educa-
tion, and being rehabilitated due to mental disorders predicted assignment to all of the three
less favorable trajectory groups. The influence of education was particularly strong with
Fig 1. Four identified trajectory groups of work participation over the period of two years before and two years after vocational rehabilitation.
https://doi.org/10.1371/journal.pone.0212498.g001
Work participation trajectories before and after vocational rehabilitation
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Fig 2. Changes in labour market status over the period of two years before and two years after vocational rehabilitation
among the trajectory groups of work participation: a) High–Resumed (N = 2554), b) High–to–Negligible (N = 1483), c)
Medium–Resumed (N = 1828), and d) Longstanding Negligible (N = 1315).
https://doi.org/10.1371/journal.pone.0212498.g002
Work participation trajectories before and after vocational rehabilitation
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Table 2. Age- and gender-adjusted predictors of being assigned to different trajectory groups of work participation around vocational rehabilitation.
High–to–Negligible Medium–Resumed Longstanding Negligible
vs. vs. vs.
High–Resumed High–Resumed High–Resumed
RRR 95% CI RRR 95% CI RRR 95% CI
Age
a
25–39 1.00 1.00 1.00
40–49 1.10 (0.92–1.32) 1.18 (1.01–1.38) 1.07 (0.89–1.28)
50–59 2.05 (1.72–2.44) 1.12 (0.95–1.31) 1.45 (1.21–1.73)
Gender
a
Women 1.00 1.00 1.00
Men 1.44 (1.26–1.65) 1.17 (1.03–1.32) 1.48 (1.29–1.70)
Region of residence
a
South 1.00 1.00 1.00
West 0.97 (0.82–1.14) 1.09 (0.93–1.27) 1.18 (1.00–1.40)
East 1.33 (1.10–1.61) 1.17 (0.97–1.40) 1.39 (1.14–1.69)
North 1.16 (0.96–1.41) 1.48 (1.24–1.76) 1.58 (1.30–1.92)
Education
a
Tertiary 1.00 1.00 1.00
Secondary 1.39 (1.19–1.62) 1.22 (1.06–1.41) 1.71 (1.44–2.02)
Primary 1.59 (1.30–1.93) 1.53 (1.28–1.84) 2.25 (1.83–2.77)
Industrial sector
b
(dummies)
Manufacturing 1.68 (1.39–2.03) 1.02 (0.84–1.24) 1.09 (0.88–1.34)
Trade 1.65 (1.30–2.09) 1.15 (0.91–1.46) 1.54 (1.20–1.98)
Transportation & storage 1.05 (0.82–1.34) 0.93 (0.74–1.17) 0.76 (0.58–0.99)
Knowledge work 1.01 (0.80–1.29) 0.78 (0.62–0.99) 0.77 (0.59–1.01)
Health & social work 0.83 (0.69–1.01) 1.18 (1.00–1.39) 1.03 (0.85–1.25)
Heavy physical work
c
None 1.00 1.00 1.00
Low 1.11 (0.86–1.43) 1.19 (0.94–1.51) 1.73 (1.27–2.37)
High 1.24 (0.96–1.60) 1.24 (0.98–1.58) 1.89 (1.39–2.58)
Kneeling and squatting at work
c
None 1.00 1.00 1.00
Low 1.10 (0.89–1.35) 1.27 (1.04–1.56) 1.31 (1.03–1.67)
High 1.09 (0.88–1.36) 1.45 (1.18–1.79) 1.70 (1.32–2.18)
Repetitive hand movements at work
c
(for 10% increase) 1.05 (1.02–1.07) 1.00 (0.98–1.03) 1.05 (1.02–1.07)
Job strain
c
Low strain 1.00 1.00 1.00
Active job 1.14 (0.88–1.48) 0.98 (0.78–1.24) 0.96 (0.71–1.28)
Passive job 1.17 (0.97–1.42) 0.96 (0.81–1.14) 1.22 (0.99–1.50)
High strain 1.53 (1.24–1.89) 1.18 (0.98–1.43) 1.56 (1.24–1.95)
Monotonous work
c
No 1.00 1.00 1.00
Yes 1.34 (1.17–1.54) 1.14 (1.00–1.31) 1.17 (1.00–1.36)
Sector of rehabilitation
a
Private 1.00 1.00 1.00
Public 0.62 (0.54–0.72) 0.90 (0.79–1.03) 0.72 (0.62–0.84)
Disease group of rehabilitation
a
(dummies)
Musculoskeletal 1.25 (0.96–1.61) 1.17 (0.92–1.49) 1.18 (0.90–1.55)
(Continued )
Work participation trajectories before and after vocational rehabilitation
PLOS ONE | https://doi.org/10.1371/journal.pone.0212498 February 21, 2019 10 / 19
respect to the Longstanding Negligible trajectory. Furthermore, many common factors pre-
dicted assignment to the High–to–Negligible and Longstanding Negligible trajectory groups,
including age 50–59, living in Eastern Finland, employment in the trade sector, repetitive
hand movements at work, high job strain, being rehabilitated in the private rather than in the
public sector, and generally also being rehabilitated during either shorter or longer periods
than the common period of exactly three months. Some common factors also predicted assign-
ment to both the Medium–Resumed and the Longstanding Negligible trajectory groups, such
as living in Northern Finland, exposure to kneeling and squatting at work, and starting reha-
bilitation in year 2008. Other factors were associated with one of the trajectories specifically:
employment in the manufacturing sector, monotonous work, and being rehabilitated due to
nervous diseases with the High–to–Negligible trajectory, being rehabilitated due neoplasms
and injuries with the Medium–Resumed trajectory, and exposure to heavy physical work with
the Longstanding Negligible trajectory.
We then assessed mutually adjusted predictors of being assigned to the different trajectory
groups (Table 3). The analyses included only those for whom industrial sector and occupation
could be identified. Most of the associations were similar to those in the age- and gender-
adjusted models. However, employment in the health and social work sector now predicted
assignment to the Medium–Resumed and the Longstanding Negligible trajectory groups. The
associations between employment in the manufacturing and trade sectors with the High–to–
Negligible trajectory nevertheless remained. With respect to job exposures, only the associa-
tions of high exposure to kneeling and squatting with the Medium–Resumed trajectory and of
high job strain with the Longstanding Negligible trajectory remained. In addition, compared
to the High–Resumed group, being rehabilitated in the private sector now predicted assign-
ment to each one of the other three trajectory groups.
Table 2. (Continued)
High–to–Negligible Medium–Resumed Longstanding Negligible
vs. vs. vs.
High–Resumed High–Resumed High–Resumed
RRR 95% CI RRR 95% CI RRR 95% CI
Mental 1.32 (1.01–1.74) 1.34 (1.04–1.72) 1.63 (1.23–2.15)
Neoplasms 1.24 (0.79–1.95) 1.69 (1.13–2.52) 1.27 (0.79–2.04)
Nervous 1.67 (1.16–2.42) 1.29 (0.90–1.83) 1.18 (0.79–1.78)
Circulatory 1.20 (0.82–1.77) 0.85 (0.58–1.25) 0.91 (0.59–1.39)
Injuries 0.93 (0.65–1.35) 1.42 (1.03–1.95) 1.32 (0.92–1.89)
Start year of rehabilitation
a
2008 1.00 1.00 1.00
2009 0.95 (0.81–1.12) 0.90 (0.77–1.04) 0.79 (0.67–0.93)
2010 0.88 (0.75–1.03) 0.83 (0.72–0.96) 0.75 (0.64–0.89)
Duration of rehabilitation
a
<3 months 1.60 (1.33–1.91) 0.74 (0.62–0.88) 1.75 (1.46–2.10)
3 months 1.00 1.00 1.00
>3 months, 6 months 1.37 (1.15–1.63) 1.04 (0.90–1.22) 1.03 (0.86–1.24)
>6 months 1.34 (1.11–1.61) 0.99 (0.83–1.17) 1.29 (1.07–1.56)
a
Including all: N = 7180.
b
Including those for whom industrial sector was identified: N = 7020.
c
Including those for whom occupation was identified: N = 6895.
https://doi.org/10.1371/journal.pone.0212498.t002
Work participation trajectories before and after vocational rehabilitation
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Table 3. Mutually adjusted predictors of being assigned to different trajectory groups of work participation around vocational rehabilitation.
High–to–Negligible Medium–Resumed Longstanding Negligible
vs. vs. vs.
High–Resumed High–Resumed High–Resumed
RRR 95% CI RRR 95% CI RRR 95% CI
Age
25–39 1.00 1.00 1.00
40–49 1.17 (0.97–1.41) 1.22 (1.04–1.44) 1.19 (0.98–1.45)
50–59 2.25 (1.87–2.71) 1.19 (1.00–1.41) 1.76 (1.44–2.14)
Gender
Women 1.00 1.00 1.00
Men 1.21 (1.03–1.42) 1.18 (1.01–1.37) 1.27 (1.07–1.52)
Region of residence
South 1.00 1.00 1.00
West 0.96 (0.81–1.13) 1.08 (0.93–1.27) 1.13 (0.94–1.36)
East 1.36 (1.12–1.65) 1.15 (0.95–1.39) 1.30 (1.05–1.61)
North 1.17 (0.96–1.42) 1.49 (1.24–1.78) 1.46 (1.19–1.80)
Education
Tertiary 1.00 1.00 1.00
Secondary 1.30 (1.08–1.56) 1.24 (1.04–1.47) 1.65 (1.33–2.03)
Primary 1.43 (1.14–1.79) 1.60 (1.29–1.98) 2.25 (1.75–2.89)
Industrial sector (dummies)
Manufacturing 1.53 (1.24–1.90) 0.94 (0.76–1.16) 0.94 (0.74–1.19)
Trade 1.59 (1.21–2.09) 1.01 (0.77–1.33) 1.25 (0.93–1.67)
Transportation & storage 0.92 (0.69–1.23) 0.80 (0.60–1.05) 0.67 (0.48–0.92)
Knowledge work 1.03 (0.79–1.34) 0.80 (0.62–1.03) 0.78 (0.58–1.05)
Health & social work 0.99 (0.79–1.25) 1.36 (1.11–1.66) 1.31 (1.03–1.67)
Heavy physical work
None 1.00 1.00 1.00
Low 1.08 (0.76–1.53) 0.88 (0.63–1.23) 1.36 (0.90–2.07)
High 1.14 (0.78–1.68) 0.80 (0.55–1.16) 1.19 (0.76–1.87)
Kneeling and squatting at work
None 1.00 1.00 1.00
Low 0.92 (0.69–1.24) 1.27 (0.95–1.69) 1.06 (0.76–1.48)
High 0.97 (0.70–1.33) 1.39 (1.02–1.90) 1.24 (0.87–1.76)
Repetitive hand movements at work (for 10% increase) 0.99 (0.96–1.03) 1.00 (0.96–1.03) 1.02 (0.98–1.06)
Job strain
Low strain 1.00 1.00 1.00
Active job 1.18 (0.90–1.56) 1.05 (0.81–1.35) 1.08 (0.79–1.48)
Passive job 0.92 (0.74–1.15) 0.91 (0.75–1.12) 1.06 (0.83–1.35)
High strain 1.18 (0.91–1.53) 1.15 (0.90–1.47) 1.35 (1.02–1.80)
Monotonous work
No 1.00 1.00 1.00
Yes 1.12 (0.92–1.36) 1.18 (0.98–1.43) 1.01 (0.81–1.24)
Sector of rehabilitation
Private 1.00 1.00 1.00
Public 0.78 (0.64–0.95) 0.84 (0.70–0.99) 0.68 (0.56–0.84)
Disease group of rehabilitation (dummies)
Musculoskeletal 1.14 (0.87–1.48) 1.20 (0.93–1.54) 1.21 (0.90–1.63)
(Continued )
Work participation trajectories before and after vocational rehabilitation
PLOS ONE | https://doi.org/10.1371/journal.pone.0212498 February 21, 2019 12 / 19
Discussion
Main findings and their interpretations
Using a nationally representative sample of vocational rehabilitees, we identified four typical
work participation trajectories over a period of two years before and two years after their epi-
sode of vocational rehabilitation that started in 2008–2010. Over one third and around one
fourth of the rehabilitees followed trajectories where initial high or initial medium level of
work participation, respectively, was resumed after vocational rehabilitation. The remaining
less than 40% of the rehabilitees followed trajectories where either an initial high level of work
participation rapidly declined reaching a negligible level one year after vocational rehabilita-
tion or where work participation was at a negligible level already more than one year before
vocational rehabilitation and remained at that level. To our knowledge, this is the first study to
provide information on latent trajectories of work participation around vocational
rehabilitation.
In our data, those who resumed their initial high level of work participation can be consid-
ered as the most favorable group with typical return to full duties after sickness absence and
the rehabilitation episode. The three less favorable trajectory groups were generally associated
with older age, male gender, living in Eastern or Northern Finland, having less than tertiary
education, being rehabilitated in the private sector, being rehabilitated due to mental disor-
ders, starting rehabilitation in 2008 instead of in the two later years, as well as being rehabili-
tated during shorter or longer periods than the typical three-month period.
Those who resumed their initial medium level of work participation can also be considered
as a relatively favorable group. This was the group for which partial work disability was most
common both before and after vocational rehabilitation. Return to partial duties could have
been an alternative to full disability retirement and therefore promoted overall work
Table 3. (Continued)
High–to–Negligible Medium–Resumed Longstanding Negligible
vs. vs. vs.
High–Resumed High–Resumed High–Resumed
RRR 95% CI RRR 95% CI RRR 95% CI
Mental 1.53 (1.15–2.03) 1.58 (1.22–2.07) 2.14 (1.56–2.92)
Neoplasms 1.34 (0.84–2.12) 1.91 (1.26–2.89) 1.58 (0.95–2.63)
Nervous 1.65 (1.13–2.41) 1.30 (0.90–1.88) 1.33 (0.86–2.06)
Circulatory 1.25 (0.85–1.86) 0.98 (0.66–1.46) 1.18 (0.75–1.86)
Injuries 0.89 (0.61–1.30) 1.48 (1.06–2.06) 1.31 (0.89–1.95)
Start year of rehabilitation
2008 1.00 1.00 1.00
2009 0.94 (0.80–1.11) 0.91 (0.78–1.06) 0.81 (0.68–0.96)
2010 0.90 (0.76–1.05) 0.83 (0.72–0.97) 0.77 (0.64–0.91)
Duration of rehabilitation
<3 months 1.61 (1.34–1.93) 0.73 (0.61–0.88) 1.72 (1.42–2.08)
3 months 1.00 1.00 1.00 (1.42–2.08)
>3 months, 6 months 1.30 (1.09–1.55) 1.04 (0.89–1.22) 0.96 (0.78–1.17)
>6 months 1.26 (1.04–1.53) 1.00 (0.84–1.19) 1.28 (1.04–1.57)
Including those for whom industrial sector and occupation was identified: N = 6895.
https://doi.org/10.1371/journal.pone.0212498.t003
Work participation trajectories before and after vocational rehabilitation
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participation. Indeed, our earlier studies suggest that being on partial work disability prevents
later full disability retirement [30,31]. Factors associated with this trajectory in particular were
prior employment in the health and social work sector, prior high exposure to kneeling and
squatting at work, and being rehabilitated due to neoplasms or injuries.
Among those who had a negligible level of work participation already before vocational
rehabilitation, full disability retirement was very common, while the use of partial work dis-
ability benefits at any period was virtually non-existent. Factors associated with this trajectory
in particular were prior employment in the health and social work sector as well as high prior
exposure to job strain. Furthermore, lower education had a particularly strong association
with this trajectory.
Those whose initial high level of work participation rapidly declined and, despite vocational
rehabilitation, reached a negligible level typically transitioned to full disability retirement or
unemployment. This trajectory in particular was associated with prior employment in the
manufacturing and trade sectors as well as with being rehabilitated due to nervous diseases.
Previous studies have indicated that previous employment [2–5,7,9] and shorter length of
preceding disability [1,5,8] were associated with more favorable employment outcomes after
vocational rehabilitation. We nevertheless demonstrated that for a relatively large group of
rehabilitees, work participation declined to a negligible level despite a high level of work partic-
ipation before vocational rehabilitation. Furthermore, another group of rehabilitees even
somewhat exceeded their initial medium level of work participation despite commonly having
periods of work disability and unemployment before vocational rehabilitation. Previous labor
market participation therefore appears to determine the outcomes to a limited extent, and
vocational rehabilitation may be successful even among those who are not currently attached
to the labor market. Previous findings from Finland indicated that vocational rehabilitation
was associated with return to work after temporary disability retirement [32].
In line with our findings, many previous studies also indicated that younger age [1–3,5,7–
10] and higher educational level [1–4,6–8,10] were associated with more favorable employ-
ment outcomes after vocational rehabilitation. These factors are likely to be associated with
better work ability or employment opportunities more generally. In our study, living in South-
ern or Western Finland was also likely to be associated with better employment opportunities
than living in Eastern or Northern Finland, where employment rates were lower [24]. In addi-
tion, employment careers were likely to be more secure in the public than in the private sector.
Previous findings from Sweden indicated that work resumption after vocational rehabilita-
tion was higher in the manufacturing industry than in other sectors [18]. Somewhat contradic-
torily, we found that prior employment in different industrial sectors had heterogeneous
influence and prior job exposures had very limited influence on work participation trajectories
around vocational rehabilitation. Employment in the manufacturing or trade sectors was asso-
ciated with the trajectory where an initial high level of work participation rapidly declined to a
negligible level. Economic and structural changes during our study period likely led to reduced
employment opportunities in the manufacturing sector and changes in the types of jobs avail-
able in the trade sector [33]. Those who were exposed to kneeling and squatting and job strain
as well as those who were employed in the health and social work sector were the most likely
to follow the trajectories where work participation was either at a medium or low level already
before vocational rehabilitation. Earlier rehabilitative efforts, combined with employment ser-
vices that could reduce unemployment after rehabilitation, might therefore be beneficial for
these groups of employees. A recent meta analysis on active labor market programs indicated
that on the average, programs promoting the accumulation of human capital, such as training
and subsidized private sector employment, have better potential to increase employment than
Work participation trajectories before and after vocational rehabilitation
PLOS ONE | https://doi.org/10.1371/journal.pone.0212498 February 21, 2019 14 / 19
other types of programs [34]. More research is nevertheless needed to determine which partic-
ular services are most effective for individuals with work disability histories.
Previous studies have found either no effects [1,2,7,9] or mixed effects [3,5,6,8,10] of gender
on employment outcomes after vocational rehabilitation. We found that men followed less
favorable work participation trajectories. Men could have been employed in segments of the
labor market where adapting to new work tasks or occupations was more difficult. Somewhat
surprisingly, however, the gender difference persisted even after controlling for education,
industrial and employment sectors, as well as different job exposures. Previous studies indi-
cated that men have fewer contacts with health care services [35–37] and lower rates of sick-
ness absence [38–41] than women. The smaller proportion of men in our present study
population also reflects their lower participation in vocational rehabilitation. These issues may
indicate lower morbidity and better work ability among men, but they may also indicate that
men have poorer or delayed access to treatment or that men are less prone to report sick.
When men do enroll in vocational rehabilitation, it may be at a later and more severe stage of
work disability compared to women.
Differences in employment outcomes after vocational rehabilitation by disease group have
also been somewhat unclear. Many studies have focused on particular disease groups [1–
3,8,9]. Studies comparing different disease groups found that employment outcomes were
more favorable among rehabilitees with physical health problems than among those with men-
tal disorders [6,7,10]. Furthermore, a systematic review focusing on overall workplace inter-
ventions directed at workers on sick leave suggested that the interventions may be associated
with more favorable labor market outcomes among those with musculoskeletal diseases, but
not necessarily among those with mental disorders [42]. In accordance, we found that those
with mental disorders followed less favorable work participation trajectories around vocational
rehabilitation than those with other diagnoses. We also found that those with musculoskeletal
and circulatory diseases followed the average trajectories. Furthermore, those with nervous
diseases were more likely than those with other diagnoses to follow the trajectory where an ini-
tial high level of work participation rapidly declined to a negligible level. Those with neoplasms
and injuries were more likely than average to follow the trajectory where initial medium level
of work participation was resumed. Such work resumption can be considered as a successful
outcome; the individuals in question may have had a condition severe enough, e.g. cancer or
injury, that reduction in work ability due to the condition or its treatment impeded return to
normal duties without vocational rehabilitation.
Prevailing economic conditions may influence labor market outcomes after vocational
rehabilitation [6,43]. We found that those who started their rehabilitation in 2009 or 2010
were less likely to follow the trajectories where initial work participation was at a medium or a
low level than those who started their rehabilitation in 2008, i.e. before the peak of the eco-
nomic recession. This may have been caused by selection: especially among those with weak
work attachment, the recession may have decreased the likelihood of receiving vocational
rehabilitation because of increased risks of unemployment and being outside the labor force.
We found that both shorter and longer than the typical three-month duration of vocational
rehabilitation were associated with the two trajectories with negligible levels of work participa-
tion after rehabilitation. Duration may have been related to the type of vocational rehabilita-
tion received, on which we did not have information. In the Finnish system, work try-outs
typically last for a few months, while work counselling typically lasts for six months or more.
The duration of training may vary considerably, the content ranging from short courses to
training programs lasting for several years [23]. In our data, the vocational rehabilitation epi-
sodes could have included successive vocational rehabilitation efforts of different types, mak-
ing findings relating to the duration of vocational rehabilitation hard to interpret.
Work participation trajectories before and after vocational rehabilitation
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Furthermore, particularly short durations of vocational rehabilitation may have indicated that
the vocational rehabilitation program was interrupted. However, even among those who
received rehabilitation for less than three months in our data, 74.3% of the episodes ended
because the fixed-term vocational rehabilitation benefit came to an end, thereby not suggesting
premature exit from the program. The rest of these short episodes ended because of unspeci-
fied reasons, including return to work.
Methodological considerations
Our study had various strengths. The study population consisted of individuals who were
derived from a large nationally representative sample and who had participated in a statutory
nationwide program of vocational rehabilitation. The register-based data did not have missing
information or loss to follow-up. Moreover, the rich data comprised detailed longitudinal
information on employment participation, vocational rehabilitation, other benefit receipt, var-
ious sociodemographic factors, industrial sector, and occupation. Using specific occupational
codes, the data were further complemented with information on various job exposures based
on previously developed job exposure matrices. Furthermore, by using a semiparametric
group-based modelling strategy, we provided novel findings on latent trajectory groups of
work participation around vocational rehabilitation. Including information on work participa-
tion both before and after vocational rehabilitation reduces some of the confounding effect of
labor marker history on subsequent labor market outcomes [19].
Our study also had limitations. The pension insurers conducting the vocational rehabilita-
tion do not systematically collect data on the provided services. We therefore did not have
information on the specific type of vocational rehabilitation or on characteristics of the pro-
vider. Neither did we have information on treatment history nor on potential receipt of medi-
cal rehabilitation. In Finland medical rehabilitation is conducted separately from vocational
rehabilitation and it is therefore not a part of the vocational rehabilitation process. Labor mar-
ket outcomes may depend on whether the provided services include e.g. educational, job-
related, medical, or other rehabilitation [4,8,18,19,44–46]. Our study focused solely on non-
medical, employment-oriented vocational rehabilitation, provided to people with relatively
good previous labor market attachment. Results for particular service contents within such
rehabilitation may nevertheless largely vary from the presented average ones. Moreover, by
excluding vocational rehabilitation episodes lasting more than 22 months, our findings may
not apply to prolonged episodes such as those related to successive vocational rehabilitation
efforts of different types or to longer-term training programs.
In addition, by using the job exposure matrices, we did not capture variation in the working
conditions between individuals holding the same occupational title. The influence of job expo-
sures on the work participation trajectories may therefore have been underestimated.
It was beyond the scope of this study to assess the effectiveness of vocational rehabilitation
on work participation. Favorable or unfavorable work participation trajectories do not neces-
sarily mean that vocational rehabilitation was successful or unsuccessful, respectively. Some
individuals may still have had good chances of return to work irrespective of whether or not
they took part in vocational rehabilitation. Others may have been less responsive to vocational
rehabilitation or, for one reason or another, may not have participated in vocational rehabilita-
tion during an optimal time frame. In our data, full disability retirement and unemployment
were relatively common already before vocational rehabilitation, suggesting that interventions
were not always carried out at early stages of reduced work participation. Further nationwide
studies are needed to assess the effectiveness of vocational rehabilitation on work participation
outcomes, taking into consideration both individual and work-related factors.
Work participation trajectories before and after vocational rehabilitation
PLOS ONE | https://doi.org/10.1371/journal.pone.0212498 February 21, 2019 16 / 19
Conclusions
Work participation trajectories and associated changes in other labor market statuses before
and after vocational rehabilitation appear to be diverse. Previous levels of work participation
were commonly resumed after vocational rehabilitation, but at the same time work participa-
tion could decline to negligible levels despite high initial levels. Less favorable work participa-
tion trajectories appear to be generally associated with older age, male gender, living in areas
with poorer employment opportunities, lower education, employment history in the private
sector, and mental diagnoses.
Author Contributions
Conceptualization: Taina Leinonen, Svetlana Solovieva, Kirsti Husgafvel-Pursiainen, Mikko
Laaksonen, Eira Viikari-Juntura.
Data curation: Eira Viikari-Juntura.
Formal analysis: Taina Leinonen, Svetlana Solovieva.
Funding acquisition: Eira Viikari-Juntura.
Methodology: Taina Leinonen, Svetlana Solovieva, Mikko Laaksonen.
Project administration: Eira Viikari-Juntura.
Writing – original draft: Taina Leinonen.
Writing – review & editing: Svetlana Solovieva, Kirsti Husgafvel-Pursiainen, Mikko Laakso-
nen, Eira Viikari-Juntura.
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