Mapping European Welfare Models: State of the Art of Strategies for Professional Integration and Reintegration of Persons with Chronic Diseases

Background: Persons with chronic diseases (PwCDs) often experience work-related problems, and innovative actions to improve their participation in the labor market are needed. In the frame of the European (EU) Pathways Project, the aim of the study is to compare existing strategies (policies, systems, and services) for professional (re-)integration of PwCDs and mental health conditions available at both European and national level between different European welfare models: Scandinavian, Continental, Anglo-Saxon, Mediterranean, and “Post-Communist”. Method: The European strategies were identified by an overview of relevant academic and grey literature searched through Medline and internet searches, while national strategies were explored through questionnaires and in-depth interviews with national relevant stakeholders. Results: The mapping of existing strategies revealed that, both at European and national level, PwCDs are often considered as part of the group of “persons with disabilities” and only in this case they can receive employment support. European countries put in place actions to support greater labor market participation, but these differ from country to country. Conclusion: Strategies targeting “persons with disabilities” do not necessarily address all the needs of persons with chronic diseases. Countries should consider the importance of employment for all to achieve smart, sustainable, and inclusive growth.


Introduction
Chronic diseases, or non-communicable diseases (NCDs), are broadly defined by the World Health Organization (WHO) as diseases of long duration and generally slow progression and are the result of a combination of genetic, physiological, environmental and behaviors factors [1]. Based on this definition, that provides the more holistic framework to approach the complexities involved in the relation of chronic diseases and employment, the terms "non-communicable diseases" and "chronic diseases" are interchangeably used in this manuscript.
Over one-third of the European population aged 15 years or older lives with a chronic disease and 23.5% of the working population in the EU suffer from a chronic illness, while two out of three people at retirement age have at least two chronic conditions [2]. Evidence shows that chronic diseases have a significant impact on labor supply in terms of workforce participation, hours worked, job turnover and early retirement [3]. For individuals with chronic conditions, those diseases also mean barriers to employment and stigma, with consequences on wages, earnings, and positions reached/level of seniority in an organization [4]. Moreover, it has been extensively observed that chronically ill employees have reduced employment prospects, as many of them experience difficulties either staying at work or returning to work after a period of absence [5]. Persons with longstanding health problems, in fact, face higher rates of unemployment and inactivity [5]. Based on the data of the 2011 ad hoc module of the EU Labor Force Survey [6], the employment rate in EU-28 for persons with limitations in work caused by a health condition (38.1%) was 29.6 percentage points less than for people with no such limitations (67.7%). According to a recent systematic review [7] a poor health state and presence of a chronic disease are important predictors of exit out of paid job due to entering the disability pension, unemployment, or early retirement schemes. A poor health and a chronic disease can negatively influence the likelihood of entering paid jobs among unemployed people [8].
However, work is a protective factor for PwCDs. Carlier et al. demonstrated that those who re-entered paid work were three times more likely to change from poor to good health and twice more likely to change from poor to good quality of life than those who continued to be unemployed [9]. Other studies confirmed that entering paid employment had a positive effect on physical and mental health [10,11]. Moreover, encouraging the rapid return to work for PwCDs is a fundamental objective for the economy in every work context [3]. Therefore, allocation of resources for professional integration or re-integration of PwCDs can be considered as investment.
Even if the relationship between poor health and unemployment is consistent across Europe, previous studies have highlighted that it seems to vary across the type of welfare state regime [7,8,12]. The consequences of poor health on employment status, in fact, also depend on social and labor market circumstances, e.g., the level of protection for workers with chronic diseases against workforce exclusion, the rehabilitation policies, the inclusion of people with poor health in regular or sheltered employment.
It is important to consider that, following the definition of disability of the Convention on the Rights of Persons with Disabilities (PwD) [13] and due to the burden they experience in daily life, many PwCDs can be as well considered PwD. This fact has been corroborated by diverse studies [14,15], and becomes also clear if we look at the Global Burden of Disease Study [16,17], which overwhelmingly identified NCDs, many times chronic conditions, as the ones mostly associated to disability. In fact, most people who receive disability benefits in Europe have chronic diseases.
Considering the above, the objective of this study is to compare existing strategies for professional integration and reintegration of persons with chronic diseases, including mental health conditions, available at both European and national level between different European regions, considering cultural and social differences. This comparison of existing strategies provides relevant stakeholders, especially policy makers, with an overview including a set of useful practices that could be transferred between countries or used across European countries.

Materials and Methods
This study was carried out in the frame of the EU-funded project PATHWAYS (PArticipation To Healthy Workplaces And Inclusive Strategies in the work sector), a 3-year project that involves 12 partners from 10 different European countries, namely Austria (AT), Belgium (BE), Czech Republic (CZ), Germany (DE), Greece (EL), Italy (IT), Norway (NO), Poland (PL), Slovenia (SI) and Spain (ES), with the aim to develop innovative approaches to promote the professional integration and reintegration of people with chronic diseases and improve their employability (www.path-ways.eu).
For the purposes of this study, persons with chronic diseases in general and persons with disability in general were considered; persons with disability were included as usually most people who receive disability benefits have chronic diseases and experience significant levels of disability in daily life [18]. Moreover, the disease groups that constitute mental disorders, musculoskeletal disorders, cancer, neurological, metabolic, and respiratory and cardiovascular diseases were selected based on their impact on labor market participation and on their contribution to years lost due to disability (YLD) in Europe [19].
The study analyzed existing strategies that are currently operating at EU and at national level in ten countries: the nine countries from which partners of the consortium belong to, with the exclusion of Belgium (because the partner is an European Association that does not operate at National level) and the inclusion of United Kingdom (UK), in order to represent the five European welfare models: • Anglo- Strategies considered in this study included the levels of policies, systems, and services. Policies are binding and non-binding legislative frameworks, provisions and approaches that set a course or a principle of action at local, regional, national, or international level (e.g., anti-discrimination law). System strategies include supports, programs, or schemes (including financial support) aimed at promoting employment. Services strategies encompass activities by private or public entities aimed at assisting jobseekers in finding employment as well as social services that directly or indirectly contribute to the employability of persons with chronic diseases.

European Level Strategies
The European policies, systems and services were identified by an overview of relevant academic and grey literature searched through Medline and internet searches on the web from May 2015 until April 2016. Data from sources such as Eurostat, European Statistics of income and Living conditions, the Academic Network of European disability experts (ANED), The Organization for Economic Co-operation and Development (OECD) and European Commission reports were included. The internet searches were done in English for materials published within the past ten years (since 2005). Webpages of relevant European and International organizations were also consulted. Examples of search terms were "chronic diseases" (in general) and specific disease groups: "mental disorders", "musculoskeletal disorders", "cancer", "neurological", "metabolic", "respiratory" and "cardiovascular diseases"; employment, integration, reintegration, return to work; job maintenance. To have a more comprehensive overview of European policies on the inclusion of persons with ill-health in the labor market, it was decided to consider a wide range of policies areas, including policies on the rights of persons with disabilities, inclusion and anti-discrimination, and employment. Although these policies do not necessarily specifically address chronic illnesses, they do provide overarching frameworks that may promote work (re-)integration policies for persons with chronic diseases. The study takes a closer look at frameworks shaped by European institutions with an objective to improve the employment of persons with chronic diseases. Policies supporting employment (re-)integration of persons with chronic diseases both directly (e.g., specifically targeted at PwCDs) and indirectly (i.e., PwCDs as parts of broader categories, disability or other) were considered.
It should be noted that this study considers only those policies, measures and services that deal with employment. Thus, the study does not consider policies focusing solely on the health aspects of NCD prevention and control.

National Level Strategies
National strategies were collected in the ten countries mentioned above (Austria, Czech Republic, Germany, Greece, Italy, Norway, Poland, Slovenia, Spain, and United Kingdom) through a multi-step approach. The first step was the distribution of questionnaires to national experts, in local languages, carried out by the partners of the Pathways project. The questionnaire included questions about national-level legislation regulating the employment of persons with reduced work capacity, disease/disability-specific legislation, schemes, and services (questionnaire is available on request). In each country, 10 questionnaires were distributed among the national experts, selected by each partner, in different fields related to employment and chronic diseases (both in general and specific chronic diseases), to ensure the coverage of all 7 chronic disease categories selected. The second step was in-depth interviews conducted by all partners of the Consortium with representatives of three main categories of key stakeholders: Users (persons with chronic diseases or advocacy groups), Professionals (healthcare or social care professionals, including medical practitioners) and Authorities (national, regional, local governments or policy makers). Interviews focused on the same areas of the questionnaire but allowed more in-depth exploration of the national situation and the filling in of possible gaps derived from the questionnaires. Whenever indicated or suggested from the expert stakeholders interviewed, we searched for also national grey literature in the local language to integrate the information collected. Convenience sampling was used as the main sampling procedure both for questionnaires and interviews; specifically, stakeholders from national organizations with expertise on employment and health issues or specialized on the different diseases (with focus on patients' associations/self-help groups) were invited to complete the questionnaire and to conduct in-depth interviews. It was decided to involve stakeholders dealing with chronic diseases in general, or/and with the above-mentioned disease groups: mental disorders, musculoskeletal disorders, cancer, neurological, metabolic, and respiratory and cardiovascular diseases; moreover, also stakeholders dealing with employment and disability in general were included. Stakeholders invited included: policy makers, experts/professionals in the field of employment re-integration of PwCDs, employers in the private sector, and representatives of patients' associations -located in the ten European countries of the project Consortium. The third step was a validation of the final findings of the study, emerged from the analysis of questionnaires and interviews, through two focus groups in April 2016 involving the partners. Project partners provided their expert knowledge at national level to fill in the gaps in identified strategies (prior to the focus group, they were asked to conduct an additional research on internet and ask follow-up questions to respondents). They were also asked to provide feedback on the identified strategies and engaged in the discussion on the final classification of the strategies.
The available strategies captured through questionnaires and interviews were classified into policies, systems, and services. Based on these categories, they were compared across different welfare models. The mapping of strategies for professional (re-)integration of persons with NCDs in the ten selected countries has been carried out following the structure outlined below: Policies: • Availability of legislative frameworks on chronic diseases, mental health, and employment; • Availability of legislative frameworks on disability and employment; • Policy provisions on mainstream and specialist employment programs; • Policy provisions on access to employment support; • Policy provisions promoting persons-centered approach and individualized service provision; • Policy provisions on localized and accessible employment service provision; Systems: • Employment support in the open labor market; • Employment support through social enterprises or social cooperatives; • Employment support through sheltered work; • Incentives for persons with NCDs to participate in activation programs; • Financial incentives for employers to recruit/retain persons with NCDs; • Non-financial incentives for employers to recruit/retain persons with NCDs; • Duties of persons with NCDs to participate in activation programs; • Duties of employers (e.g., quota systems); Services: • Availability of general and specialized employment services for persons with NCDs.

European Level Strategies
The detailed comparative results on European level strategies found are shown in Table 2, considering both policies supporting employment (re-)integration of persons with chronic diseases directly and indirectly. In general, the overview of the European strategies shows that the focus is almost exclusively on policies that concern the high level of European framework definition. The search has revealed that to a large extent the employment activation of persons with NCDs is targeted through: Policy provisions specifically focusing on the professional (re-)integration of PwCDs are often part of broader policy frameworks. For example, the EU Strategic Framework on Health and Safety at Work 2014-2020 specifically mentions supports in recruitment and return to work of people with a chronic or rare disease, disability or mental conditions, and the use of integrated employment measures such as individualized support, counselling, guidance, access to general and vocational education and training, and other.
There is also a number of policy reports and actions specifically targeted at chronic diseases or at particular chronic conditions (e.g., Reflection Process on Chronic diseases: Final Report, Joint Action on Chronic Diseases (JA-CHRODIS), Green Paper on Improving the mental health of the population, Joint Action Mental health and Well-being, CANCON Joint Action 2014-2017).
The detailed descriptions of all the European strategies found, is available on the website of the project (www.path-ways.eu) and as Supplementary Material to the manuscript.

National Strategies
In total, 84 questionnaires and 31 interviews were carried out for the following countries: United Kingdom (Anglo-Saxon model); Norway (Scandinavian model); Austria, Germany, and Slovenia (Continental model); Greece, Italy, and Spain (Mediterranean model); Czech Republic and Poland (Post-Communist model). The complete lists of respondents per country are included in the appendix (Questionnaire: Appendix A (Table A1), and interviews: Appendix B (Table A2)). Table 3 reports the detailed results about national policies and systems, emerged from the analyses of questionnaires and interviews.

National Policies Legislative Frameworks specifically on Chronic Diseases and Employment
According to the responses to questionnaires and interviews, in all the countries reviewed in this study, there are no legal frameworks specifically covering the employment integration of PwCDs. In most cases persons with NCDs are considered as part of a group of persons with disabilities and reduced work capacity. Therefore, they might be covered by legislation for persons with disabilities to some extent-depending on type of chronic disease and type of national classification system.

Legislative Frameworks on Mental Health and Employment
In the case of mental health conditions, more specific frameworks are available. For instance, Norway has in place a National Strategic plan on Work and Mental Health, and in the UK, a national strategy, "Five Year Forward View for Mental Health", for the National Health Service in England has been published.

Legislative Frameworks on Disability and Employment
Legislative frameworks on disability in all countries provide a solid foundation for fighting against discrimination in employment and employment services. All countries have ratified the United Nations Convention of Rights of Persons with Disabilities (UNCRPD) and at least at policy level it provides the framework to recognize the rights of persons with disabilities to equal work opportunities. Depending on the definition of disability in different countries, persons with chronic health conditions can be recognized as "disabled" and be protected from unfair treatments and inequalities or benefit from additional supports.

Policy Provisions on Mainstream and Specialist Employment Programs
In all countries Public Employment Services aim to provide services to persons with reduced work capacity and have units or personnel that can refer jobseekers with specific needs to specialized services.
Policy Provisions Allowing Access to Employment Rehabilitation Support for Persons with NCD, without Making Disability a Prerequisite All countries provide support to persons with disabilities or persons from vulnerable social groups in finding, getting, and staying in employment. However, in most countries this support is not automatically available for persons with chronic diseases. In all countries from the Mediterranean welfare model, disability is a prerequisite for additional support in job seeking. In Greece, for example, persons with NCDs with a disability level below 50% cannot access employment rehabilitation programs, regardless if they still have support needs. A similar situation exists in Austria, but the assessment of disability varies in both countries. In some cases, as in Poland, people have no chance to work at all if they are found "incapable of doing any gainful work". In Spain, persons with chronic diseases, however, still have a possibility to access assistance in job adaptation. In the UK and Norway, persons with health conditions are included in provisions for employment support. For example, in the UK, persons with cancer would automatically get access to same services that are available for persons with disabilities.

Policy Provisions Promoting Stakeholder Cooperation and Integration of Services
Differences exist in the degree of cooperation between healthcare and employment bodies in defining rehabilitation plans for persons with NCDs. At the stage of assessment, some countries still rely on a medical approach, without considering other factors (IT, SI, PL, EL).
In terms of the cooperation between companies and healthcare professionals, countries like UK and Norway have return-to-work or long-term absence management mechanisms that enforces the link between these stakeholders. In this sense, the IA-Agreement in Norway is an example of the government's attempt to ensure a greater involvement of employers. The Corporate Integration Management System (BEM) in Germany is another example.

Policy Provisions Promoting Persons-Centered Approach and Individualized Service Provision
The understanding of the importance of a person-centered approach and individualized services is seemingly shared by all countries, at least on paper. However, when it comes to the actual implementation of such services, a lot depends on the personnel of the employment services handling the case. Like in the case of Czech Republic, a lack of sufficient funding overwhelms labor offices, thus creating a risk that the needs of jobseekers are not adequately assessed.

Policy Provisions on Localized and Accessible Employment Service Provision
Mediterranean countries such as Italy and Spain have differences between regions in terms of supports and services available. While difference can be regarded as a possibility to provide more diverse and locally suited support mechanisms, it may also create unequal services for people depending on where they live. In the UK and Norway, employment services that operate through local branches, are in this sense more uniform.

National Systems Employment Support in the Open Labor Market
Policies in all countries are targeted to integration into the open labor market. However, the effectiveness of such measures and the quality of their implementation can vary.
Supported employment schemes are embedded in national policies and strategies in some countries (DE, AT, SI, ES) and takes different forms while keeping to the same principles in others. In Poland, for example, supported employment services are not mainstreamed but are rather available through individual projects (often funded by the European Commission).

Employment Support through Social Enterprises or Social Cooperatives
Social enterprises take different forms across countries. One of the most varied and business-focused forms of social economy presented in this study is the one of the UK. The market approach can be seen in the business approach and terminology that is used regarding social enterprises as they draw resources from social "investments", rather than government "subsidies." In some cases, social enterprises are so dependent on government support or not interested in economic sustainability, that their "commercial" activities can be questioned (e.g., some Vocational Rehabilitation Facilities in Poland).

Employment Support through Sheltered Work
In most countries, sheltered works are considered as the last resource for persons who are not able to be employed in the open labor market. They are often targeted at persons with (severe) intellectual/developmental disabilities and some people with mental health conditions but are not entirely relevant for persons with other chronic diseases.

Incentives for Persons with NCDs to Participate in Activation Programs
There are basically two ways in which persons with NCDs can be incentivized:

•
Benefits that are conditional on participating in work-related activities (e.g., Work assessment Allowance, Qualification benefit, and Support when participating in measures in Norway; Employment and support allowance for certain recipients in the UK); • Possibility to keep benefits while working. Most countries give this possibility depending on the degree of disability (e.g., DE, CZ, and ES).

Financial Incentives for Employers to Recruit/Retain Persons with NCDs
Most countries provide wage subsidies, nearly all temporary, with exception of the UK.

Non-Financial Incentives for Employers to Recruit/Retain Persons with NCDs
Non-financial incentives mainly take a form of corporate social responsibility commitments (CSR). Larger companies that have occupational health therapists also have a possibility to provide return-to-work programs and manage long-term sick leaves with an aim to have a positive impact on their workforce. In the UK and Norway, where there are no quota obligations or substantial financial incentives for employers, emphasis on non-financial incentives is important, such promoting diversity at workplace and highlighting the benefits of hiring and keeping persons with health problems.

Duties of Persons with NCDs
There are three main groups of countries regarding the responsibility of persons with disabilities (including NCDs) to participate in activation measures:

•
Countries that have a rehabilitation-before-benefits rule (NO, UK); • Countries that have rehabilitation-before-benefits provisions in place but are not (adequately) implemented (DE, AT); • Countries that do not have the rehabilitation-before-benefits rule (All Mediterranean and Post-Communist model countries reviewed in this report).

Duties of Employers
Most countries have quota systems for persons with disability, thus some including people with NCDs, with exception of the United Kingdom and Norway.

General and Specialized Employment Services for Persons with NCDs
Among the categories of chronic health conditions considered in this study, mental health condition is the one that most frequently has specialized services. Employment services for persons with mental health conditions are specific in a way that they require more psychological support and follow up from personal coaches. For the rest of the categories of NCDs, the services are less specialized and persons with those condition use general services available for persons with disabilities. Exceptions are made when patients' associations, specialized in specific diseases, provide services to their target users (e.g., cancer associations, associations of persons with respiratory system problems). Such services usually focus on provision of information, support in coping strategies, etc.). A detailed description of all the services available per country is available on the website of the project (www.path-ways.eu) and as Supplementary Material to the manuscript.

Discussion
The objective of this study was to compare existing strategies for professional integration and reintegration of persons with chronic diseases available at both European and national level between different European regions. The mapping of policies, systems and services facilitating the inclusion of PwCDs at European and national level has revealed that in most countries individuals from this group are considered as part of a group of persons with disabilities, including persons with reduced work capacity due to illnesses. Persons with specific chronic health conditions considered in this study can mainly receive support in employment if their condition can be recognized as a "disability" in their countries (reaching a certain eligible degree of disability) or have a negative impact on their work ability. The fact that legislation for persons with disabilities does not always benefit people with chronic diseases could be related to the way how disability is defined in the country: the population that benefits from disability policies is considerably restricted for those countries that use a narrow definition of disability as a personal characteristic of a minority, while is broader for those countries adopting a more inclusive definition of disability, in line with the definition proposed by WHO [28]. Basing on the definition of disability of the Convention on the Rights of Persons with Disabilities, persons with disabilities are persons who have "long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others" [13]. Following this definition and due to the burden they experience in daily life, many persons with chronic diseases can be as well considered PwD. Persons with chronic conditions in fact experience considerable disability in daily life, ranging from problems in body functions to limitations in activities, and important restrictions in their participation in society.
The study shows that there is a general consistence between European and national legal frameworks regarding the activation of persons with disabilities and disadvantaged groups. Countries considered in this report do put in place provisions to support activation and greater labor market participation, but they do it in different ways.
In terms of policies, all countries have legislative frameworks against discrimination and provide some support to persons with disabilities and illnesses. Policy-level strategies targeted at activating PwCDs, are, on the other hand, more limited. They are targeted through strategies for broader groups (persons with disabilities, vulnerable social groups, elderly, etc.). Most policies highlight the significance of availability of mainstreamed, person-centered, integrated, and accessible employment services. However, the implementation of policies often does not go in line with the initial commitments, thus hampering the effectiveness of policies and programs. In addition, the existence of legal initiatives on work activation of PwCDs does not necessarily coincide with a change in attitudes towards their employment in the society.
In terms of systems, countries differ from each other based on how much emphasis they put on supports, incentives or obligations in order to facilitate the integration of persons with disabilities and reduced work capacity. For instance, as an integration policy-oriented country, the UK provides fewer categorized support services, no financial incentives to employers in a form of wage subsidies and requires unemployed persons with reduced work capacity to participate in work-related activities. Norway, a Nordic welfare state, operates in a similar way, but it does provide wage subsidies to employers and provides a wide range of services aimed at empowering workers with health problems. Continental welfare states considered in this study have more categorization in terms of disability recognition, which makes the access to certain employment supports more difficult. These countries provide financial incentives and use quotas to activate employers but do not impose additional requirements on jobseekers. In Mediterranean welfare states the situation is fairly similar. Greece, however, due to financial difficulties, has very limited supports and activation measures. There, as well as in Post-Communist states considered in this report, funding from the EU plays an important role in providing support.
In terms of services, the range of specialized services for most categories of chronic conditions is limited. Persons with chronic conditions receive mainstream employment services or services tailored for persons with disabilities or reduced work capacity. Out of all the categories of chronic conditions considered, for mental health conditions there are more specialized strategies in place. This may be explained by the markedly different needs of persons with such conditions and the fact that mental health has been high on the international agenda.
The recent difficult economic situation in Europe has led to the reduction in social protection expenditure and restricted the access to sickness and disability benefits in 2011 in most EU Member States [3]. A study by Saltman and others found that financial pressure and slower economic growth in Europe have led to decreased funding for healthcare and necessitated reforms to improve the sustainability of public funding of healthcare [29]. Financial pressure has led to reforms in pension schemes that aim to extend working life. Such reforms have made the withdrawal of older workers from the labor market in case of unemployment less likely than before [30].
It can be hypothesized that budgetary constraints and the impacts of the economic crisis have led to the contracting of the passive compensation-oriented policy and the expansion of the integration-oriented policy in European countries, although at different scales in different states. Despite having an overall tendency that is headed in the same direction-the direction of activation-the pathway of each country towards promoting employment integration is unique. Comparisons are difficult to make, due to differences among countries in cultural, historical, and economic backgrounds, in institutional and social settings, in approaches to chronic diseases and disabilities, etc.
Moreover, a European study has identified that the supply of support in terms of adaptations of workplace and work content does not necessarily meet the needs of persons with chronic diseases [5]. In other words, not everybody with support needs is actually provided with such assistance. For example, in Belgium, 53% of workers with chronic diseases requested an adaptation of tasks, but only 34% of them obtained this support; in the Czech Republic 27.6% reported work adjustment needs but only 11.4% received support [5].
Another issue to be considered, is related to the ambivalent function of the social benefits, that can lead to the risk of the benefit trap, making people with ill-health more dependent on passive income supports and discouraging them from entering the labor market. The reduction of the labor force, in turn, has a negative impact on the economic growth. According to a study [31], there will be a potential shortfall of around 35 million workers, or about 15% of the total labor demand, by 2050. For this reason, it is important to ensure an inclusive labor market that would be able to meet the future labor demand and contribute to sustainable growth. Such inclusive markets can be made possible if every person at working age is given a possibility to participate in the open labor market and is provided with adequate support in doing so.
Participation of PwCDs in the open labor market can contribute to tackling the above-mentioned socio-economic challenges. As explained above, it has a potential to alleviate poverty and social exclusion, to encourage higher employment rates and labor supply, and to reduce public spending on disability benefits. Besides this, employment can have a positive impact on the well-being and mental health [32].
The results of our Pathways study are in line with previous one that confirms that, in addition to health-related obstacles, there are also non-medical factors that perpetuate long-term sick leaves and prevent persons with chronic conditions from returning to work, including personal, societal, and work-related obstacles [33]. Such factors include older age, lack of vocational rehabilitation counseling, and lack of cooperation from employers in modifying working conditions. In contrast, factors such as a better control of individual working conditions, personal guidance and support from health authorities and health professionals, and a positive attitude of the persons have been among factors that facilitate the return to work [33].
Therefore, the types of support provided to persons with NCDs in returning to or staying in employment should not be limited to health-related rehabilitation only but should encompass environmental adaptations and accommodations, thus adopting a biopsychosocial approach to employment.
Reduced unemployment, social equality, and higher labor market participation are among the main priorities set by the EU's Europe 2020 strategy, in which the importance of participation of all working-age people regardless of their skill level in the labor market has been widely acknowledged [34]. To achieve inclusive and sustainable growth, everyone should be given an opportunity to enter and remain in the open labor market, including persons with NCDs. Hence, there is a need for implementing effective strategies to ensure their maintenance, integration, or reintegration in the labor market.
Furthermore, these results stressed the importance of employment for ensuring the quality of life of persons with chronic diseases and for achieving smart, sustainable, and inclusive growth under the Europe 2020 Strategy. Work in fact does not only have an impact on the quality of life of individuals, but also contributes to social cohesion by making people feel that they are part of society.
Some limitations of this study should be mentioned. First, even though our search was extensive, it was not systematic, and we therefore cannot be sure that all relevant articles and reports were included. Second, the use of a convenience sampling to contact national stakeholders as respondents to questionnaires and interviews, can limit the generalizability of our results. Another limitation is related to the complexity of the situation in terms of employment strategies for persons with chronic diseases. We are aware that, within both the professional communities and the academic literature, there is a large degree of variation in the use of the term "chronic disease", in the diseases that are included under the umbrella term "chronic disease", and in the time a disease must be present for something to be referred to as chronic; this variation in meaning is amplified when viewed in an international context. Moreover, big differences exist between different categories of chronic diseases, individual diseases included in each category, as well as personal characteristics of each person with a chronic disease. On top of this, co-morbidities are also widespread. Including more conditions would have been ideal, but the number of CDs to be included could not be too broad because of the limitations imposed by the three years funding of the project. In this sense, the complexity of the topic and research scope was one of the main challenges of the present study. Finally, from a theoretical point of view, the definition of "welfare models" adopted in our project is complex, because a lot of factors exist that can modify these systems in a context where European social models face several challenges such as the financial sustainability, the globalization, and the social changes; again, the framework of our project imposed us to follow this categorization.
Despite these limitations, the study presents the following strengths: first, it provides a unique overview of employment strategies for persons with chronic diseases in various European countries and at different levels (policies, systems, services): identifying strategies in countries from different welfare models allowed exploration of potential commonalities and differences and identifying possible trends in the region. Second, it covers a wide range of chronic diseases, geographical locations, welfare models, levels of implementation (European and national).
Our results constitute an important starting point, but further research is needed to explore in detail the efficacy of the existing strategies and study the peculiarity of each country and the specific pathway of different chronic diseases.

Conclusions
Statistics for Europe clearly show that NCDs pose a serious problem to society by negatively affecting labor market participation. The developmental risks associated with chronic diseases require high level policy intervention.
To a large extent, existing European and national policy frameworks on employment activation are not specifically targeted to accept a decrease in functioning of workers due to health conditions, thus allowing all (including PwCDs) to be included in employment. Instead, they target broader categories, such as persons with disabilities, long-term unemployed, vulnerable groups, etc. Emphasis should be made on the fact that strategies targeting persons with disabilities do not necessarily address the needs of patients with chronic diseases and mental health conditions since the employment needs of these groups are not always the same. Identifying the work-related needs of PwCDs and developing tailored interventions may be important for secondary prevention of illness becoming chronic. Furthermore, a more integrated and favorable service provision environment (employment support integrated with healthcare, social and psychological support), as well as more involvement from the part of employers, is crucial to promote a real inclusion of PwCDs in the labor market.
Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/15/4/781/s1, File S1: The full report "Comparison of available strategies for professional integration and reintegration of persons with chronic diseases and mental health. Report based on five categories of social welfare models in Europe", that includes the detailed reports for each Country, is available online at www.path-ways.eu.