11 General introduction also establishes identity and structure in everyday life [1-4]. This focus on work is reflected by the way current social security systems support people to stay at or return to (any) work, even partially or with adjustments [1, 5]. Over the last few decades, many industrialized countries have reformed their disability insurance programs to encourage work participation by long-term sick-listed employees who have residual work capacity (1). This shift in focus generally reflects the underlying idea that being able to work is a key to regaining health, economic self-sufficiency, and social standing [3, 6]. Although work participation is encouraged, people with chronic diseases have been found to have lower employment rates than people without chronic diseases. OECD reported in 2010 that employment rates of people with disabilities were low compared to those of people without disabilities. For example, in that period for all 27 OECD countries, employment rates were respectively 43% for workers with chronic diseases versus 75% without chronic diseases [1]. Moreover, in 2010 in the Netherlands nearly 25% of persons with chronic diseases worked 12 hours per week or more, compared with 67% of the total work force [7]. Persons with chronic diseases not only work less often [8], but on average they also work 9 hours per week less compared to the total work force [7]. Inability to Work Fulltime Inability to work fulltime literally means that a person cannot sustain working activities for normal fulltime working hours. Although this sounds clear, for physicians who have to decide whether a specific worker with a somatic or mental health condition is able to work fulltime is not easy. It depends on several factors, including non-medical ones. The ability of a person to be active in day-to-day working life is an important aspect of functioning at the level of the whole human being. The International Classification of Functioning and Health (ICF-model) describes functioning at three levels: body functions and structures, activities, and participation [9]. The factors influencing functioning are divided into three categories: health condition, personal factors, and environmental factors. Inability to work fulltime can be seen as a restriction in participation, an inability to work fulltime at any occupation, due to a combination of health-, personal-, and environmental factors. Being unable to work fulltime can have both a negative and, surprisingly, a positive impact on a person’s functioning in daily life (including work). For example, when people who are no longer able to work fulltime cannot fully re-integrate into their fulltime jobs, this can lead to involuntary loss of their jobs and (partial) work disability benefits. The employer may experience loss of productivity and expertise and face the extra costs of replacement. Society is also burdened with the extra costs of unemployment or work disability benefits. Nevertheless, in spite of the negative impact of being unable to 1
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