Abstract
BACKGROUND:
Post-stroke return-to-work (RTW) rates reported in Singapore ranged between 38% and 55%, indicating challenges in the RTW process among individuals with stroke.
OBJECTIVE:
We sought to understand the lived experience of returning to work among individuals with stroke in Singapore.
METHODS:
This was a qualitative study using a phenomenological approach. We recruited individuals with stroke who were citizens or permanent residents of Singapore. We conducted semi-structured interviews to collect data on their lived experience of returning to work and analyzed the interview data inductively.
RESULTS:
Twenty-seven participants completed the interviews. Their median age was 61 years (interquartile range = 54 – 64). They were mostly male (n = 19, 70.4%) and married (n = 21, 78%). Twenty participants (74%) returned to work after their stroke. Three major themes emerged from the interviews that underpinned the participants’ RTW experience. They were i) direct impact of stroke, ii) realignment of life priorities, and iii) engagement with support and resources.
CONCLUSION:
RTW after stroke is complex and influenced by personal and environmental factors. Our findings suggest that individuals with stroke need continuing support to overcome stigma and discrimination, to manage expectations of their recovery process, and to better navigate resources during their RTW process in Singapore. We recommend future studies to design and test the feasibility of appropriate interventions based on our proposed strategies to better support individuals with stroke to return to work.
Introduction
Stroke is a leading cause of disability worldwide [1]. With advances in healthcare, the mortality rate after stroke has dropped, which has subsequently led to an increase in the number of individuals living with disability after stroke [2]. In Singapore, it is estimated that 63% of individuals with stroke develop some form of disability [3]. Stroke-related disability can negatively impact on daily functioning and participation in valued life activities, such as work [4].
Many individuals with stroke value work and are interested in resuming work [5]. This is because being employed is an important part of adult life – it gives a sense of identity and social status, while allowing individuals to meet their financial needs [5–7]. However, individuals with stroke might not be able to return to work due to physical, cognitive, psychosocial, and environmental challenges [8, 9]. There is a wide range of return-to-work (RTW) rates reported internationally [10, 11]. In comparison, previous studies in Singapore reported RTW rates between 38% and 55% [12–16]. The proportions of individuals with stroke returning to work in Singapore may indicate that these individuals do face challenges in their RTW process – this opinion was similarly expressed by a panel of localexperts [17].
The impact of stroke on employment requires attention in Singapore. Being out of work may present financial challenges to individuals with stroke despite the availability of a national social security scheme (i.e., the Central Provident Fund) [18]. While all Singapore citizens or permanent residents who are employed make contributions to their individual accounts, the ability to make withdrawals from these accounts is subjected to stringent criteria. Individuals with stroke who are below 55 years old can make withdrawals only if they have been certified as having severe disability. Otherwise, they can only apply to make withdrawals once they have reached 55 years of age. The quantum of the withdrawals also depends on the total amount of money saved in the account and can vary between individuals [18]. Therefore, individuals with stroke may feel pressed to return to work if they are unable to make withdrawals or perceive these withdrawals as being inadequate. Further, given that the crude incidence rate for stroke has risen over the past 10 years [19], the number of individuals with stroke seeking to return to work may have increased. It is therefore increasingly important to understand how individuals with stroke navigate their RTW process to achieve their vocational goals. However, there are limited local published studies on the subject matter. Past studies have been mostly retrospective chart reviews [12, 16] or did not focus on the stroke population [13], and thus could not provide detailed information on the experience of RTW after stroke in Singapore.
In this study, we sought to explore the lived experiences of returning to work among individuals with stroke in Singapore. This study will facilitate a better understanding of the challenges faced by such individuals so that appropriate recommendations can be made to support their RTW process.
Methods
Study design
This was a qualitative study using a phenomenological approach. Phenomenology focuses on understanding the lived experiences of individuals undergoing a particular phenomenon, such as returning to work after stroke. The fundamental goal of the approach is to derive themes that describe the phenomenon in question [20].
Participants
Individuals were eligible for the study if they were Singaporean citizens or permanent residents staying in Singapore, above 21 years old, and formally diagnosed with stroke. They were not eligible if they could not understand and communicate in English adequately to provide informed consent and complete the in-depth face-to-face interview.
Recruitment and data collection procedures
We retrieved the contact details of individuals with stroke from an existing research database after obtaining ethical approval. We mailed a study invitation letter to them. Two weeks later, we made a follow-up telephone call to these individuals to explain the study, establish their interest to participate in the study, and determine their eligibility. If they were interested and eligible, we scheduled a face-to-face interview with them at a time and place of their preference (e.g., at the participant’s home, or at the university). We obtained written informed consent from the individuals before the interview commenced. We recorded the interviews on digital audio-recording devices with their permission. We asked them to complete a socio-demographic questionnaire after the interview wascompleted.
Interview guide
We developed a semi-structured interview guide to elicit responses regarding our participants’ experiences of returning to work. The interview guide included open-ended exploratory questions and corresponding probes. Some examples of the questions were “How did stroke affect your work or employment?” and “What did you do to return to work after stroke?”
Data processing and analysis
We transcribed the audio-recordings of the interviews verbatim and verified the transcripts against the audio-recordings prior to analysis. We based our analysis on the inductive analytical process by Miles and Huberman [21]. Initially, we worked independently to familiarize ourselves with the transcripts, including developing memos and preliminary codes for the transcripts. Subsequently, we discussed our memos and preliminary codes as a group to enhance the rigor of the analytical process. We conducted these group discussions iteratively to refine and build consensus on the codes and categories (i.e., coding structure) that comprehensively represented the data. We used this finalized coding structure to analyze all transcripts. We organized relevant categories into appropriate themes to answer our research question. We also summarized the participants’ demographic characteristics using descriptive statistics such as medians and interquartile ranges, and frequencies and percentages.
We performed member checking with our participants to enhance the credibility of the data. After each interview was completed, we prepared a personalized interview summary. We contacted the participants via telephone and read the individualized interview summary to them. We noted any corrections or additional information offered by the participants and included them during the data analysis phase.
Ethics
We obtained ethical approval to conduct this study from the National University of Singapore Institutional Review Board (Reference code: S-17-185).
Results
Participants’ socio-demographic and employment characteristics
We interviewed twenty-seven participants between November 2017 and December 2018. The interviews lasted for a median duration of 50 minutes (interquartile range = 33 – 55). The median age of participants was 61 years (interquartile range = 54 – 64). A majority of participants were male (n = 19, 70%), Chinese (n = 20, 74%), and married (n = 21, 78%). All participants were employed prior to their stroke and 20 (74%) reported returning to work. There were no statistically significant differences in age, gender, marital status or ethnicity between participants who returned or did not return to work. The participants’ socio-demographic characteristics are presented in Table 1.
Summary of participants’ demographic and employment information (N = 27)
Summary of participants’ demographic and employment information (N = 27)
Three themes emerged from the interviews that described the factors influencing our participants’ experiences of returning to work after stroke. These were 1) direct impact of stroke, 2) realignment of life priorities, and 3) engagement with support and resources. A summary of the themes and other supporting quotes are presented in Tables 2 to 4.
Theme 1 – Direct impact of stroke (categories, definitions, and additional supporting quotes)
Theme 1 – Direct impact of stroke (categories, definitions, and additional supporting quotes)
Theme 2 – Realignment of life priorities (categories, definitions, and additional supporting quotes)
Theme 3 – Engagement with support and resources (categories, definitions, and additional supporting quotes)
This theme represents the direct impact of stroke on the participants’ social integration, functional abilities, and vocational skills. There were four categories identified: a) stigma and discrimination, b) impairments after stroke, c) independence in community living skills, and d) match between abilities and work demands.
Stigma and discrimination
Some participants reported feeling self-conscious and stigmatized because of their stroke. They did not feel comfortable when they were being stared at, or if members of the public approached them to ask questions about their stroke condition. Experiencing such incidents caused them to feel a sense of embarrassment. Hence, not returning to work was a way to prevent these undesirable social situations.
Working ... is a problem for me anyway. People would stare. That, I cannot take. People say always, “You know, don’t care what other people think.”But then, when it happens to you, it’s a different story. A lot of times, my friends would always say, “Don’t care what people say, what people think. Just don’t care!”It’s different you know, when it happens to you. You feel like, as if the ground swallowed you up. –Gina, 54, female, ticketing agent
Other participants also remarked that there may be discrimination against people with stroke. For example, Lawrence, a painter, reported receiving lesser job offers when prospective clients knew about the stroke. In addition to their stroke, some participants also considered their age as a factor in returning to work. Although it was not a direct impact of stroke, they felt they were less employable given their stroke condition and older age.
Impairments after stroke
Participants generally reported that their stroke resulted in physical impairments, such as loss of strength in the hemiplegic limb, poor endurance, and fatigue. These impairments affected their ability to perform basic tasks. Stroke also impacted on the participants’ emotional status. For some participants, mood fluctuations after stroke seemed to affect their energy levels and became a consideration in their RTW process.
I mean, sometimes my mood, our mood ... you know, ah, on and off. And sometimes I feel very tired. Tired. Then I don’t think I’ll do anything. That’s why I don’t intend to work. Stay at home, better. –Valerie, 65, female, clerk
Independence in community living skills
The physical impairments participants experienced affected their ability and confidence being in the community, prior to RTW. They shared concerns about being able to be independently engage in community activities, for example, to take public transport safely, to travel long distances alone, or even to buy their meals. These concerns caused participants to re-evaluate their readiness to return to work.
I don’t know ... a lot of things like, because I [am] scared [to take the] MRT (i.e., a local rail transport) also, the first thing ... then transport, then meals also ... Then I said don’t want [to go back to work]. –Doreen, 53, female, immigration officer
Match between abilities and work demands
Participants shared that their ability to perform at work was also influenced by their impairments. Some participants perceived a mismatch between their post-stroke abilities and work demands. They were concerned that they were not able to perform assigned work tasks or meet required work standards. Such concerns made them hesitant to return to work.
You know, because my work is like, I’m on the phone too. Sometimes, [making ticket] reservation. I get stuck talking. I don’t know what you call this. But you know like, I cannot get the words out of my mouth, which is something new. I was never like that ... Yeah. So, sometimes I know what I want to say but I get tongue-tied. Then, I get frustrated. “Ahh!I don’t want to talk!” –Gina, 54, female, ticketing agent
On the other hand, there were participants who experienced relatively mild impairments after their stroke. They did not perceive or encounter much difficulty with performing work tasks. Hence, RTW was a natural transition after the impairments were resolved.
I still can cope because mentally I was still okay, I didn’t suffer any impairment there. It was only the hand [that] was weakened, and the numbness slowly wear off ... At least with one hand, I can still fulfil most of the functions, because my job doesn’t require the use of the left hand so much, you see ... so it’s not so bad, I could still function. –Benjamin, 71, male, office manager
Theme 2: Realignment of life priorities (seeTable 3)
This theme represents how participants’ life priorities were affected by stroke. There were four categories identified: a) prioritization of health over work, b) the value of work, c) new lifestyles after stroke, and d) responsibilities towards self and others.
Prioritization of health over work
After their stroke, many participants seemed to place a greater emphasis on their recovery and rehabilitation over returning to work. For some participants, this sometimes meant achieving a state of physical functioning close to, or equal to their pre-stroke status. They were not ready to consider returning to work when their health status or recovery progress did not meet their personal expectations, or if they perceived any uncertainty in their health status should they return to work.
I think health ... health is more important for me at the moment. I’d rather retire and recover my health rather than deteriorate my health. I don’t know what will happen during the work, if I fall down or I collapse ... So rather than to earn that money, I’d rather rest and recover. –Ivan, 56, male, property manager
The value of work
For participants who did not return to work after stroke, they shared a negative re-evaluation of work. Work was deemed as being stressful, and work-related stress was perceived as the cause of their stroke. Returning to work meant that these participants would be returning to stressful environments which could be detrimental to their health. Hence, returning to work was the less desirable option. Others shared that the job opportunities being offered to them were not interesting or did not meet their personal preferences. For example, Mark, previously a businessman, rejected a position as an attendant in a jackpot lobby, because the work was mundane and went against his principles.
For the work you do, to me, it’s not that stimulating. It’s nothing interesting ah. So, I rejected them. And also, it’s for gambling purposes, which to me... I don’t feel it’s the right way to go. So I said no. –Mark, 61, male, businessman
Work was viewed positively by some other participants. They shared that there were benefits to returning to work after stroke. These benefits included using time more productively, maintaining social contact with peers, and even having value as therapy or exercise.
You stay at home also, too boring. And then sometimes, if you see a movie, you cannot see so much. If you go to friends, that means they are not so free, some of them are working. So might as well, I work one week once, to see all my friends ... To pass the time, and to make more friends, and then to speak to some more people. If you speak to some passengers, you still gain knowledge. [Interviewer: Can I say that work for you, is interesting?] Quite interesting. –George, 80, male, security officer
Eugene, an administrator-cum-volunteer at a local food distribution center, remarked that work fulfilled a spiritual aspect of his life. He perceived his work as a way of serving his community.
So like for example, we are doing this food distribution to please the Lord and please the people. So happy, no problem. So this way, it’s not that we are trying to be selfish, you know, think of myself, my children, my family, and then don’t do anything else. Then that is not good. –Eugene, 53, male, administrative officer
New lifestyles after stroke
Throughout the recovery process, participants found time to engage in different activities while they were not at work. Over time, some participants became used to these activities, which formed new routines and lifestyles. As they adjusted and found meaning in these new routines and lifestyles, they were less keen to consider returning towork.
I would have to take it day by day, because currently, my mother is going to dialysis as well, so three times a week. And sometimes, I have to go there and cook for her or take care of her. And it actually takes up some of my time ... So definitely, I can’t go to work. There are priorities, so who should come first? Mother or your work ... but, I mean, it’s a blessing I am not working now, so I can help them as well. So yeah, it’s also good. –Jacob, 56, male, self-employed
Other participants who were older and closer to the retirement age seemed to consider stroke as an indication that it was time to rest and retire. They acknowledged that it was time for a change of pace after having worked for a long time.
In these four years since, I got used to it. At home, and freedom, in-out like that. That’s why, if you work ah, it’s like pressure you know? Everything must work, work ... I don’t want. I want to have freedom... [Interviewer: You wanted to resign after your stroke?] Yes. I asked for retirement ... Early retirement, because I am 60 years old already. I have been working there for 20 years. –Valerie, 65, female, clerk
Responsibilities towards self and others
Stroke led many participants to re-evaluate their personal financial needs. Some participants shared that being affected by stroke may require long-term medical expenses. If they did not return to work, the loss of income might impact their health and well-being in the future. Others commented that being financially independent i.e., having a source of income, was beneficial as they did not have to rely on others.
You get income. Then you get freedom. Then you can do whatever you want ... When I work, I can do things that I want. I can travel, I can go out with friends, I can spend money and do whatever I want.
–Nora, 61, female, tutor
There were some participants who were the main breadwinners for their families. They had little choice but to return to work to support their family members, for example, to pay school fees for their children.
But what to do? I must do my own business, [even for] a little bit, for the survival of my daughter ... My daughter is schooling, must pay, everything must take care.
–Rodney, 63, male, self-employed
Other participants considered the impact of stroke on their caregivers. They shared that they did not want to burden their family members, who had other responsibilities of their own. Hence, returning to work was a way that they could reduce the caregiving burden on others, while remaining a productive member of the family.
As long as I don’t give burden to my siblings. This is what I tell myself. And I can still support my mom, I can pay the utilities, and I can do marketing for my mom.
–Faris, 54, male, taxi driver
Theme 3: Engagement with support and resources (seeTable 4)
This theme represents the types of support and resources participants engaged with during their RTW process. The four categories identified were: a) unexpected barriers, b) support from employers and colleagues, c) support from family, and d) seeking information and services.
Unexpected barriers
Some participants encountered challenges that prematurely ended their job search. Mark described how searching for jobs on the Internet can be a one-sided affair, with a lack of responsiveness or limited assistance provided after a job application was submitted. He continued to say that there was a lack of service coordination between organizations that were intended to support the RTW process.
You see the problem is, um, seems most of my search through social networks, or through Internet, it’s difficult to see direct barriers, other than no response, and not being able to get any assistance ... There seems to be no single center where you get assistance: government offices, disability centers, or whatever ... it’s still very fragmented.
–Mark, 61, male, businessman
Oscar (62, male, self-employed) reported that while a community-based organization provided a job-matching service, poor physical accessibility and the long travelling distance to the organization made it too tedious for him to receive services. Another participant mentioned that the administrative processes he had to undergo while accessing services were lengthy, unhelpful and made him feel less dignified as a person.
Because, what made me really frustrated at one time ... I asked at the family service center for financial assistance, because I was not working. The officer treated me like beggar. That’s why I felt fed-up ... because the way the lady talked, “I cannot support you.”She told me like that. I told the officer, “Hello madam, I know you cannot support me, you think what? I want the money? I worked, last time I worked, I am getting three, four thousand a month. You give me two hundred, you think I am really hard up? I’m not hard up, but I am fed-up!”
–Faris, 54, male, taxi driver
Support from employers and colleagues
Participants shared that a key source of support for RTW came from their employers and colleagues. Some participants felt fortunate to have bosses or colleagues who were willing to welcome them back to work. The encouragement from their workplace colleagues helped them to feel less anxious about returning to work.
It’s the hospital. The hospital, I should say, initiated it, me going back to work. And they kind of fought for me with the Nursing Board and all that. Kind of rationalized with them that I should be given a chance ... My hospital colleagues give me the same emotional and moral support. –Samantha, 63, female, senior staff nurse
In contrast, a perceived lack of support from the employer can be a barrier to RTW, as experienced by Penny. Although the company appeared supportive about how she could continue to contribute in her previous job role, she faced difficulty while trying to make alternative work arrangements. This led to a sense of uncertainty about how well she would be supported when she returned to work. This uncertainty eventually led her to decide not to return to work.
But getting the laptop from my office is a problem. How to go back? Can you tell me? So I called the secretary. Then my secretary ... she made a mess out of the whole thing where she took my computer without letting people know ... . And the computer was recorded as lost. I tell you, it became a mess ...
–Penny, 62, female, quality management officer
Support from family
Family members were another source of support that influenced the participants’ RTW status. Some had supportive family members who encouraged them to return to work after they had recovered from their stroke. For example, Doreen did not return to work initially. However, she eventually took to her sister’s encouragement and returned to part-time work.
Because my sister doesn’t want me to everyday stay home, so she let me [work] to occupy my time.
–Doreen, 53, female, immigration officer
Other participants commented that their family members were concerned about their health, safety and well-being while commuting to work, or being at work itself. Their family members encouraged them to rest more and expressed less support for the participants to return to work.
I want [to go back to work]!But my daughter say, “Don’t”. Because [when] driving ... if you have a second stroke, we cannot take care [of you] already ... Now rest. So [she] say no. Also cannot go and exercise by myself. My daughter say, “Don’t need.”
–Desmond, 72, male, taxi driver
Seeking information and services
Participants reported that they sought information and services across different platforms to support their RTW process. Some participants were more Internet-savvy and could be more independent in their job search. They browsed job advertisements and used job portal websites on the Internet to seek opportunities. Other participants utilized more traditional ways of seeking for jobs. They attended job fairs or sought job-related services from community-based organizations. They were also sometimes referred to such services by their healthcare professionals after indicating their interest to return to work during routine review sessions.
I was recommended by the therapist to SG Enable, [who in turn] recommended me to Dignity Kitchen (i.e., a social enterprise). There I [learnt to] bake muffin and cook chicken rice ... and it really built up my confidence [to work] ... then I planned to [return] to [being] a taxi driver.
–Faris, 54, male, taxi driver
Discussion
RTW after stroke is complex – it is a simultaneous interaction involving the individuals who suffered a stroke, multiple stakeholders, and systems [8]. Personal factors such as the individuals’ evaluations of their disabilities and capacities to work may impact their RTW process [8, 23]. At the same time, environmental factors such as support received from the individuals’ workplace or society may also influence the process [8, 23]. The similarities between our participants’ experiences and the findings reported in international studies over time [8, 23] suggest that individuals seeking to RTW after stroke may experience common challenges regardless of where they may be. Subsequently, potential recommendations to overcome these challenges in Singapore, such as the ones we propose, may be applicable and valuable to consider in other countries.
The most frequent barriers to RTW after stroke in Singapore documented by a local panel of experts were the employers’ poor knowledge of individuals with stroke, their reduced expectations of the work performance of these individuals, and the lowered motivations of these individuals to RTW [17]. In the same study, different pathways that individuals with stroke could explore to optimize their RTW process in Singapore were outlined. Our findings expanded the understanding of these barriers and pathways described by Lim et al. [17] in three categories: stigma and discrimination, prioritization of health over work, and unexpected barriers.
Stigma and discrimination
Stigma has been reported as a barrier to employment for individuals with disabilities [24]. Stigma arises when an individual’s characteristics (i.e., physical features or health condition) is deemed to be different from social norms [25]. For individuals with stroke, feelings of being stigmatized can arise from their physical impairments or even from negative encounters with other people [26]. Stigma can then lead to job discrimination if employers hold negative attitudes towards individuals with stroke [24]. Our participants’ experiences reflected both stigma (i.e., feeling less capable or normal than others, avoiding embarrassing social interactions) and discrimination (i.e., reduction or lack of job offers by potential employers).
To address stigma and discrimination, interventions may be needed for individuals with stroke, their community, and prospective employers. Interventions using a positive psychology approach [27] can shift focus from a disability-oriented perspective that emphasizes impairments and limitations, to a strengths-oriented perspective that emphasizes abilities and other positive traits [28]. For example, individuals with stroke may work with counsellors to manage the way they view themselves after their stroke. They should be supported to develop adequate coping strategies to overcome stigma that may impede their RTW process [29, 30]. Further, public education campaigns may be valuable to mitigate the impact of stigma and discrimination at a community level. Such campaigns should continue to raise awareness for individuals with stroke, and to portray them positively as capable employees. Additionally, specific outreach efforts may also be needed for prospective employers. These employers may provide reasons for not hiring individuals with stroke such as having uncertainties about being able to support such individuals at the workplace [23, 32], or that their business may be less productive and profitable [31]. Hence, education and support may be needed to encourage prospective employers to change their attitudes towards hiring individuals with stroke [22, 31]. These recommendations could facilitate positive change in the perspectives of different groups of people towards the common goal of easing the RTW process for individuals withstroke.
Prioritization of health over work
Stroke is often a sudden and highly significant event in an individual’s life. With the occurrence of stroke, individuals may be compelled to re-evaluate their life situations, including appraising work-life balance, life goals, and roles [4, 7]. Our participants reported similar experiences. Particularly, a more negative appraisal of their stroke and recovery process potentially impacted on their lifestyles and readiness to resume pre-stroke roles, such as being a worker. It was striking to learn that some participants expressed hope for greater recovery before they would consider returning to work, despite living with stroke for some years already. This finding seemed to indicate that our participants could have unrealistic expectations towards their recovery, and were still trying to adjust to, or accept their condition after stroke. Participants in other studies shared the same experiences – they felt that they were still finding ways to cope with the effects of stroke [22] or that they needed to accept their disability prior to returning to work [31]. Hence, the overall recovery process after stroke extended beyond the initial rehabilitation phase; returning to optimal living after stroke thus took a longer time [22].
One possible reason for these unrealistic expectations or adjustment difficulties may be that these individuals with stroke received limited follow-ups and information on the trajectory of stroke recovery after their discharge from stroke-related services. Such individuals may benefit from long-term post-stroke engagement and support services [8, 22]. These services can provide curated information about what they may expect from their recovery process at relevant time points. Such information may be useful for individuals with stroke to manage their expectations, priorities, and goals as they recover over time, resulting in better overall adjustment to life after stroke [8, 22]. This may then facilitate individuals with stroke to be better able to progressively seek participation in meaningful and valued life activities, such as returning to work [5, 6].
Unexpected barriers
The presence of unexpected barriers was another interesting issue highlighted by our participants. These barriers were unexpectedly encountered while our participants were accessing RTW services. Several studies reported similar challenges raised by our participants, such as lack of direct physical access to services, lack of coordination between organizations providing RTW services, and administrative or bureaucratic processes which hindered individuals with stroke from receiving the support that they may need [8, 33].
Scharwz and colleagues [8] suggested that these challenges (i.e., lack of coordination between organizations) may exist because of the complexity of the RTW process, as well as a lack of clarity of the specific responsibilities of various stakeholders in supporting the process. As a result, RTW services for individuals with stroke may be more fragmented [32]. It is vital to enhance the delivery of such RTW services. One recommendation is to have a formal RTW coordinator to advocate for individuals with stroke and to co-navigate services offered by various RTW organizations [8, 32]. Another recommendation is for legislators to develop clearer policy, guidelines and pathways for RTW services [33]. With a formalized point-of-contact to guide individuals with stroke through their RTW process, and a clearer framework for post-stroke RTW services, the experience of unexpected barriers during the RTW process may be minimized.
Limitations
Our study had two main limitations. Our participants in this study were largely comprised of individuals from the Chinese ethnic group. Hence, our findings may be less transferable to individuals from other ethnic groups. The values and perceptions towards the RTW process may vary among different ethnic groups. We recommend that future studies should include balanced numbers of individuals from each local ethnic group. This will provide greater insights into cultural or social nuances that may influence the RTW process. These insights may be important to develop culturally or socially appropriate interventions to support individuals with stroke from different ethnic groups to return to work in Singapore.
We also noted that many of our participants suffered a stroke at least five years prior to their interviews. Our participants’ experiences of the RTW process, including the barriers they faced, might be different compared to the RTW experiences of those who suffered a stroke more recently. Future studies of individuals with stroke who sought to return to work at various stages of their recovery process may be beneficial to explore if barriers to RTW remain consistent or change over the course of the process. The findings from such studies may help us identify types of resources that may be required at various stages of their recovery process to further optimize RTW post-stroke.
Conclusion
RTW after stroke is complex and influenced by personal and environmental factors. Our findings suggest that individuals with stroke need continuing support to overcome stigma and discrimination, to manage expectations of their recovery process, and to better navigate resources during their RTW process in Singapore. We recommend future studies to design and test the feasibility of interventions based on our proposed strategies to better support individuals with stroke to return to work.
Ethics statement
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1975, as revised in 2000. Informed consent was obtained from all patients prior to inclusion in the study.
Conflict of interest
The authors declare that they have no relevant financial or non-financial interests to disclose.
Footnotes
Acknowledgments
The authors would like to thank the participants who took the time to share their experiences for this study. They would also like to thank the research assistants, Ms. Yi Tian Felicity Yeo and Ms. Kalya Marisa Kee Lin, for their assistance and contributions.
Funding
The study was funded by the National University of Singapore Start-up Grant awarded to Miho Asano (Principal Investigator).