System responsiveness and health literacy in return-to-work challenges for individuals with chronic low back pain: a qualitative study

This study explores how individuals with chronic low back pain (CLBP) experience and navigate return-to-work (RTW) processes and identifies their suggestions for improving coherence in RTW processes. Seventeen outpatients from a Spine Clinic, all of whom were either currently or recently on long-term sick leave (exceeding 30 days) due to CLBP, participated in three semi-structured interviews and four focus group sessions. The data were analyzed using reflexive thematic analysis and interpreted through a health literacy (HL) perspective. Four overarching themes were constructed: Psychological vulnerability; Seeking diagnostic and RTW clarity; Lack of recognition and flexible support from stakeholders; and Absence of professional consensus in RTW planning. Each theme comprised two subthemes. By adopting an HL perspective, this study provides insight into how limited interactive and critical HL can hinder engagement in RTW processes among individuals with CLBP, particularly when combined with emotional vulnerability, diagnostic uncertainty, and fragmented service coordination. These findings suggest that HL-responsive practices may help reduce HL-related inequalities and support more coherent, equitable, and accessible RTW processes. Health literacy (HL) shapes how individuals with chronic low back pain (CLBP) engage with return-to-work (RTW) processes, particularly in systems requiring coordination across sectors.Emotional distress, diagnostic uncertainty, and fragmented service delivery disproportionately affect individuals with limited interactive and critical HL.Rehabilitation professionals should adopt HL-responsive practices, including tailored communication, structured psychosocial support, and coordinated stakeholder meetings.Rehabilitation professionals should provide differentiated navigation assistance, such as care coordinators or shared documentation tools, to help individuals manage cross-sector RTW processes. Health literacy (HL) shapes how individuals with chronic low back pain (CLBP) engage with return-to-work (RTW) processes, particularly in systems requiring coordination across sectors. Emotional distress, diagnostic uncertainty, and fragmented service delivery disproportionately affect individuals with limited interactive and critical HL. Rehabilitation professionals should adopt HL-responsive practices, including tailored communication, structured psychosocial support, and coordinated stakeholder meetings. Rehabilitation professionals should provide differentiated navigation assistance, such as care coordinators or shared documentation tools, to help individuals manage cross-sector RTW processes.