The challenge of implementing return to work programs from research to practice – a review of barriers in a systemic perspective

Introduction
Work disability due to low back pain (LBP) leads to impaired quality of life among workers, disruptions in the workplace and heavy financial burden upon society. Although workplace-based return to work (RTW) programs have demonstrated their superiority upon traditional healthcare-based rehabilitation, little uptake of these programs is observed and some implementation failures are described in the literature. The aim of this review was to identify the barriers to the implementation of RTW programs and LBP guidelines so as to further inform program developers, implementers and providers.

Methods
A literature review was performed in order to identify the barriers to (1) the implementation of RTW programs, (2) the adoption of LBP guidelines by healthcare practitioners and (3) the implementation of participatory ergonomics interventions in the workplace. A distinctive search strategy was used for each objective within major databases such as Medline, PsycINFO and CINAHL. Identified barriers were subsequently sorted at the individual, organizational and legal levels, among different categories of stakeholders.

Results
Barriers identified among healthcare professionals were lack of knowledge, lack of interest, lack of time, practices in discordance with guidelines, a biomedical vision of LBP, excessive medicalization of the problem and financial disincentives. Barriers among workplace actors were financial constraints, low level of support, organizational difficulties, lack of time, lack of communication and fear of social conflicts. Barriers among social security actors were financial constraints, lack of time, practices in discordance with internal regulations, lack of communication, fear of breaking legal requirements of health privacy and fear of healthcare expenditures.

Discussion
A number and variety of multilevel barriers are likely to impede the implementation and effectiveness of RTW programs and guidelines. It is recommended that program developers be aware of these barriers and perform a context analysis resulting in a tailored strategy prior to any implementation.