Abstract
Stroke is a leading cause of death and long-term disability in Singapore (National Registry of Diseases Office [NRDO], 2013). The incidence of stroke increased about 33% between 2007 and 2016, and among people ages 30 to 59 yr, it was significant (NRDO, 2018), indicating that an increasing proportion of younger adults are affected by stroke. The official retirement age in Singapore is 62 yr (Ministry of Manpower, 2018), so more people with stroke may seek opportunities to return to work.
People with stroke may have impairments that limit their ability to perform activities of daily living (ADLs) or productive activities such as work (Balasooriya-Smeekens et al., 2016; Brannigan et al., 2017; Sturm et al., 2002). Some may have to consider changing jobs or completely giving up work (Wolfenden & Grace, 2009). Unemployment after stroke is burdensome. At an individual level, it may have a negative impact on health and life satisfaction (Röding et al., 2010). At a societal level, it may place an economic burden on employers and governments through indirect factors, such as sick leave, early retirement, or productive years lost (Clayton et al., 2012; Westerlind et al., 2017). Thus, return to work after stroke is an important rehabilitation outcome to ameliorate the negative impact of stroke on individual workers and society (Baldwin & Brusco, 2011). The benefits of returning to work extend beyond economic considerations, such as retaining employment and income; people with stroke who return to work also experience a more positive self-image, enhanced sense of well-being, and greater life satisfaction (Treger et al., 2007).
Traditionally, the main foci of rehabilitation are to prevent medical complications and restore basic functional skills and mobility (Treger et al., 2007). For people with stroke, rehabilitation remediates stroke-related impairments and facilitates functional independence (Medin et al., 2006). However, a traditional rehabilitation approach may not be adequate to facilitate return to work for such people (Leonardi et al., 2015; Treger et al., 2007).
Vocational rehabilitation programs are made up of targeted interventions that aim to return sick or injured people to work and support them in sustaining employment (Baldwin & Brusco, 2011). Interventions may include a range of services encompassing medical, psychosocial, physical, and occupational rehabilitation activities (Baldwin & Brusco, 2011; Sinclair et al., 2014). However, international literature that sufficiently describes vocational rehabilitation programs for people with stroke is limited (Baldwin & Brusco, 2011; Wei et al., 2016). Moreover, to our knowledge, only one Singaporean study, which included 29 people with stroke (Chan, 2008), has described a vocational rehabilitation service for people with disabilities. The paucity of published literature on vocational rehabilitation programs, including in Singapore, emphasizes a need to evaluate vocational rehabilitation services for people with stroke (Edwards et al., 2018).
The primary purpose of our study was to report the return-to-work rate of people with stroke who completed a vocational rehabilitation program and to describe the impact of that program on their community reintegration. The secondary purpose was to describe the impact of the program on their physical functioning and independence.
Method
Design and Data
This was a retrospective database study. A team of occupational therapists, physiotherapists, and administrative staff collected the sociodemographic and clinical data of participants as they enrolled in and completed the program and managed the database.
Participants
Prospective participants had to meet the following eligibility criteria: Singaporean citizens or permanent residents, ages 18 to 55 yr, formally diagnosed with stroke, and certified as fit for rehabilitation by their physician. They were excluded if they were certified as permanently unfit for work by their physician, had cognitive impairments (as indicated by a score <26 on the Montreal Cognitive Assessment [MoCA]; Nasreddine et al., 2005), or were not willing to consider return to work as a rehabilitation goal. The sample analyzed for this study included only eligible participants who were age 21 yr or older.
Program
Transition to Employment (TTE) is a community-based, interdisciplinary, vocational rehabilitation program established in 2014 by SPD, a Singaporean voluntary welfare organization (SPD, 2018). It was piloted between 2014 and 2017 and aims to facilitate the return to mainstream employment of adults with acquired physical disabilities. The program administrators conducted a series of outreach presentations at public hospitals in Singapore to inform health care professionals about and raise awareness of the TTE program. These professionals then referred prospective participants to the program for further evaluation.
TTE supports mainly adults with a diagnosis of stroke or spinal cord injury. It consists of individualized services ranging from physical rehabilitation to psychosocial, employment, and caregiver support. Occupational therapists provide expertise such as assessment of the home and work environments, assistive technology exploration, work task simulation, and recommendations for job accommodations and modifications. They perform these tasks in collaboration with physiotherapists, social workers, and employment support specialists. Participants are assigned case managers from among these professionals, who coordinate their care and routinely review their progress. For this pilot program, participants were discharged when they had returned to work and sustained employment for 3 mo or when they had received rehabilitation services for a maximum duration of 2 yr.
Primary Outcomes and Measures
The primary outcomes of the study were return-to-work rate and community reintegration. Return to work was defined as successful part-time or full-time employment at the point of discharge from TTE. The return-to-work rate was calculated as the proportion of participants who returned to work after completing TTE.
Community reintegration was assessed by means of the Community Integration Questionnaire (CIQ; Willer et al., 1993). The CIQ is a self-report measure that consists of 15 items. Scores are individually calculated for three subscales: Home Integration, Social Integration, and Integration Into Productive Activity. A total score for the CIQ is obtained by adding the scores for each subscale. The total CIQ score can range from 0 to 29; higher scores indicate a greater level of community integration. The questionnaire has been reported to have excellent test–retest reliability (intraclass correlation coefficient = .96) for populations with stroke (Dalemans et al., 2010).
Secondary Outcomes and Measures
Four secondary measures—the Berg Balance Scale (BBS; Teasell et al., 2018), 6-minute walk test (6MWT; Flansbjer et al., 2005), 10-meter walk test (10mWT; Tyson & Connell, 2009), and modified Barthel Index (MBI; Shah et al., 1989)—were used, respectively, to evaluate balance, walking endurance, walking speed, and independence in performing ADLs. All four measures are valid and reliable for use with the population with stroke (Flansbjer et al., 2005; Fricke & Unsworth, 1997; Shah et al., 1989; Teasell et al., 2018; Tyson & Connell, 2009).
Data Analysis
We summarized participants’ demographic characteristics using descriptive statistics such as proportion, median, and interquartile range (IQR). We used the Wilcoxon signed-rank test (Streiner, 2010) to compare outcome measure scores within groups between program enrollment and completion and the Mann–Whitney U test (McKnight & Najab, 2010) to compare for differences in outcome measure scores between participants who returned to work and those who did not. We used nonparametric statistical analyses because the data were not normally distributed. We performed all statistical analyses using IBM SPSS Statistics for Windows (Version 25; IBM Corporation, Armonk, NY). The National University of Singapore Institutional Review Board approved the study.
Results
Participants
The database included 58 participants. Eight (14%) did not complete the TTE. The participants who completed the TTE (n = 50) had a median age of 44 yr (IQR = 38–42) and were mostly men (n = 37; 74%). A majority had hemorrhagic stroke (n = 30; 60%) and presented with left hemiplegia (n = 31; 62%). They enrolled in TTE within a median of 2 mo (IQR = 1–5) after their stroke and remained in the program for a median of 10 mo (IQR = 7–14). We found no statistically significant differences in demographic and clinical characteristics between participants who did or did not complete the program. We focused our subsequent analyses on the 50 participants who completed the program.
Return to Work
Among the 50 participants who completed the TTE, 44 returned to work (88%). We found no statistically significant differences in demographic and clinical characteristics between participants who did or did not return to work. We observed a high proportion of male participants in both groups (returned to work, n = 33, 75%; did not return to work, n = 4, 67%). Participants who returned to work spent a median of 9 mo (IQR = 7–14) in the program, whereas participants who did not return to work spent a median of 13 mo (IQR = 9–21) in the program. The 6 participants (12%) who did not return to work after completing TTE provided the following reasons: not interested in returning to work (n = 4; 8%), opted for short-term training (n = 1; 2%), and chose a self-management approach (n = 1; 2%). Table 1 summarizes the demographic and clinical characteristics of the participants who completed TTE.
Demographic and Clinical Characteristics of Participants Who Completed the TTE
Note. — = not applicable; IQR = interquartile range; Mdn = median; TTE = Transition to Employment.
Based on Mann–Whitney U test or Fisher’s exact test between participants who did and did not return to work.
Community Integration Questionnaire
The median CIQ total score of participants who returned to work was 12 (IQR = 7–16) at enrollment and 20 (IQR = 16–22) at program completion. The median CIQ total score of those who did not return to work was 7 (IQR = 5–9) at enrollment and 13 (IQR = 11–16) at program completion. We found statistically significant differences between CIQ total scores at enrollment and completion, regardless of return-to-work status (returned to work, Z = −5.447, p < .001; did not return to work, Z = −2.032, p < .05). The CIQ total scores at completion between the two groups were also significantly different (U = 37.000, p < .05). Table 2 summarizes the CIQ and secondary measure scores.
Outcome Measure Scores for Participants Who Completed the TTE
Note. BBS = Berg Balance Scale; CIQ = Community Integration Questionnaire; IQR = interquartile range; MBI = modified Barthel Index; Mdn = median; 6MWT = 6-minute walk test; 10mWT = 10-meter walk test; TTE = Transition to Employment.
Based on Wilcoxon paired signed-rank test.
Secondary Measures
We found statistically significant differences (p < .05) between enrollment and completion scores on all secondary measures for participants who returned to work. For participants who did not return to work, we found statistically significant differences (p < .05) between enrollment and completion scores only for the BBS and MBI.
Discussion
In this study, we aimed to describe how people with stroke benefited from TTE, with a focus on the return-to-work rate and community reintegration. We found that a majority of participants who completed TTE returned to work, and all participants reported higher levels of community reintegration after completing the program.
Supporting Return to Work
Seeking reemployment is an important goal for people with stroke who are of working age (Daniel et al., 2009). Vocational rehabilitation may facilitate that process. Singaporean studies have reported that between 41% and 55% of people with stroke return to work (Chan, 2008; Chan et al., 2012; McLean, 2007; Tan, 1983). However, the impact of vocational rehabilitation services on return-to-work rate was unclear because only one study (Chan, 2008) described the provision of a vocational rehabilitation service before return to work. In their review, Baldwin and Brusco (2011) reported that between 12% and 49% of people with stroke returned to work after vocational rehabilitation. A higher proportion (88%) of our participants with stroke returned to work after completing the TTE. This finding supports that a vocational rehabilitation program such as the TTE can enhance return-to-work rates.
Other factors could have contributed to the higher rate of return to work, such as a shorter duration from onset of stroke to program enrollment. Early intervention is recommended to support return to work (Dworzynski et al., 2013; Frank, 2013). We found that the median duration from onset of stroke to program enrollment for our participants was around 2 mo. This falls within the 6-mo window for maximizing functional recovery after stroke (Langhorne et al., 2011). Participants were able to be referred early because information about TTE had been actively disseminated through outreach sessions to health care professionals by the program administrators. Such early vocational support has been recommended and should be provided by closer cross-sector collaboration between community-based service providers and hospitals (Sinclair et al., 2014). Hence, a combination of early referral to and early engagement in vocational rehabilitation activities could have facilitated the return to work of more of our participants with stroke.
Not Returning to Work
Decreased motivation or work-related fears are examples of psychosocial needs that may influence whether people with stroke return to work (Alaszewski et al., 2007). People with stroke may experience psychosocial fluctuations throughout their recovery process (Hackett et al., 2012). It is therefore important to understand how they perceive their recovery process (Baseman et al., 2010). Of the 6 participants who did not return to work in our study, 4 (67%) stated that they were not interested in returning to work. Case managers could more regularly review their clients’ personal and vocational expectations throughout the vocational rehabilitation process to meet their specific needs and achieve the program’s overall goals (Walsh et al., 2015).
Community Reintegration
A person-centered approach to providing health services has resulted in a better understanding of the evolving needs of people with stroke, beyond physical issues, as they progress through their recovery and continuum of care (Hackett et al., 2012). Early stroke rehabilitation research has focused on physical or functional recovery as primary outcomes of interest (Duncan et al., 2005). More recent work in the field seems to support the inclusion of other outcomes, such as social or community reintegration (Baseman et al., 2010; Treger et al., 2007).
Community reintegration is a broad concept that includes resuming prestroke social or productive roles and relationships within the home, workplace, or society at large. The CIQ measures levels of integration at home, within society, and at work; specifically, participation in work activities is measured by the CIQ Integration Into Productive Activity subscale (Dalemans et al., 2010). In our study, participants who returned to work had a median CIQ Productive Activity subscale score of 6 out of a possible 7 and had a significantly higher CIQ total score than participants who did not return to work. We expected that as our participants returned to and engaged in work activities for 3 mo, their score on the CIQ Productive Activity subscale would increase, which would subsequently contribute to a higher CIQ total score.
It is worthwhile to note that participants who returned to work also reported significant changes on the other CIQ subscales. This finding suggests that in addition to being able to participate in work activities, they were better integrated into their homes and society. Baseman et al. (2010) stated that higher levels of community reintegration may contribute to successful return to work. We believe that improvements in one area of community reintegration (i.e., social participation) may mutually benefit other areas of community reintegration (i.e., work). Hence, it may be important to include participatory outcomes, such as community reintegration, in vocational rehabilitation programs.
Physical Functioning and Independence
Physical functional ability is regarded as one of the most important factors restricting participation among people with stroke (Chau et al., 2009). Studies have reported that better walking ability and functional status, as well as greater independence in ADLs, can significantly predict return-to-work status among people with stroke (Chan et al., 2012; Hackett et al., 2012; Vestling et al., 2003). Participants who returned to work completed the program with significantly higher scores on measures of physical functioning and independence in ADLs. Some vocational rehabilitation programs may be too specific; they may target only work-related skills such as résumé writing or preparing for interviews (Baldwin & Brusco, 2011) and overlook physical outcomes. Our study highlights that vocational rehabilitation programs should continue to facilitate improvements in these physical domains concurrently with work-related skills.
Limitations and Recommendations
This study has several limitations. The study was retrospective and based on participant information that was available in the database. There was no comparison or control group to enable us to more accurately evaluate the program’s impact. The improvements observed in this study could be attributed to other factors, such as time since diagnosis, duration of program participation, and the natural recovery process. Future prospective experimental studies are warranted to better understand the impact of vocational rehabilitation programs.
Participants who returned to work enrolled in the program with good physical functioning and independence in performing ADLs, as indicated by BBS and MBI scores. This could have influenced the return-to-work rate. Although the participants’ functional status was random, future studies should consider broader inclusion criteria that may be more representative of the general population with stroke, so as to support the return to work of people with diverse functional abilities after stroke.
Return to work is a complex process. We acknowledge that the quantitative data collected in this study may not be sufficient to provide a comprehensive understanding of how participants used services or how they perceived the benefits of the program. Future qualitative studies will be beneficial to explore participants’ experience and identify salient features that may increase the success of vocational rehabilitation programs.
Implications for Occupational Therapy Practice
People with stroke may experience reduced quality of life if they are unable to participate in productive and meaningful roles within their societies and community. Facilitating the ability of people with stroke to resume their productive roles, particularly in gainful employment, can be vital in preventing role loss after stroke and ensuring life satisfaction. This study has the following implications for occupational therapy practice:
Our study supports that early initiation of vocational rehabilitation interventions is beneficial in facilitating the return to work of people with stroke. Occupational therapists working with this population may initiate discussions about returning to work earlier in the recovery process. This approach may encourage people with stroke to remain optimistic about resuming their worker role and reduce the impact of the sick role after stroke.
Vocational rehabilitation services should be comprehensive and individualized to meet the changing needs of people with stroke throughout their recovery process. Services should include the provision of physical, emotional, psychosocial, and vocational interventions as necessary in close collaboration with service recipients. Occupational therapy is a vital component of such interdisciplinary services, and occupational therapists may be well positioned to perform coordinating roles within these services.
Assessing fitness for work can be a complex process, and it should be undertaken by an interdisciplinary team of professionals, not determined through a single medical evaluation. An occupational therapy evaluation should be conducted as part of a comprehensive assessment to determine fitness to work.
Conclusion
We found that TTE, a local community-based vocational rehabilitation program, potentially benefited participants by improving their community reintegration, physical functioning, and independence after stroke. This study supports the value of vocational rehabilitation services for people with stroke. Further intervention studies with control or comparison groups are recommended to determine the effectiveness of such vocational rehabilitation programs. Qualitative studies exploring participants’ perspectives are also recommended to identify important features that contribute to the success of these programs.
Footnotes
Acknowledgments
We thank all the Transition to Employment program participants who contributed data for this study. We also express our gratitude to the SPD staff who supported delivery of the program. This study was funded by the Ministry of Education Academic Research Fund Tier 1.