Topical Seminar 4

Topical Seminar 4:
Psychosocial Factors Involved in the RTW Process

Session chair(s): Amanda Young

Schedule Details

Tuesday September 30
10:45 - 12:15 Morning Concurrent Sessions (T O1 - T O12 and Seminar 4)
Topic: Disability determinants
Room C

Seminar Objectives

With medical models being found to insufficiently explain return-to-work (RTW), researchers have been giving more attention to the role of psychosocial variables. Of those that have been examined, workers’ expectations for RTW have been found to consistently relate to the outcomes achieved. Another construct that has shown promise is personal resilience, which has been found to be associated with a number of outcomes within the workers’ compensation setting.

The proposed seminar gathers together work on the topic of RTW expectations, resilience and related constructs. The collection includes work being conducted in Australia and the US that employs a range of methodologies (inc. qualitative and quantitative) and has varying theoretical underpinnings. Together presentations will tell a story that will provide attendees with the opportunity to further develop their understanding of these important variables, and (hopefully) a further appreciation of the role that psychosocial variables can play in influencing RTW outcomes and experiences.

The seminar would include introductions (5 minutes), four presentations (12-minute each, each followed by 5 minutes of Q&A), a general discussion with audience participation (10-15 minutes). The first presentation would be on the role of resilience in Workers’ Compensation. The second would be on direct and indirect relationships among psychosocial predictors (including RTW expectations) of RTW. The third would be on the use of a Theory of Planned Behaviour (TPB) model of RTW behaviour to identify the antecedents of future work expectations. The fourth would be on the formation of expectations for RTW.

Presentation 1: Development of an instrument assessing recovery expectations in patients with mental health disorders

Presented by: Shanil Ebrahim

Authors

Ebrahim S1,2,3,4, Malachowski C5, Kamal el Din M6, Montoya L7, Mulla S2, Bance S8, Guyatt GH1,9, Busse JW1,2

  1. Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
  2. Department of Anesthesia, McMaster University, Hamilton, Canada
  3. Department of Medicine, Stanford University, Stanford, USA
  4. Department of Anaesthesia & Pain Medicine, The Hospital for Sick Children, Toronto, Canada
  5. Department of Medicine, McMaster University, Hamilton, Canada
  6. Ain Shams University, Faculty of Medicine, Cairo, Egypt
  7. University Health Network, Toronto, Canada
  8. Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, Canada
  9. Department of Medicine, McMaster University, Hamilton, Canada

Abstract

Background

Our analysis of a Canadian disability insurance claims database showed that of those approved for long-term disability benefits, 31.6% suffer from a primary diagnosis of a mental health disorder. Negative patient recovery expectations are associated with worse outcome. Measures assessing patient’s expectations of recovery can help with early identification of individuals at risk of prolonged recovery. Our objectives were: 1) complete a systematic review to identify measures that currently assess expectations of recovery, and 2) using the results from the review, develop an instrument assessing recovery expectations in individuals receiving wage replacement disability benefits secondary to mental health disorders.

Methods

We completed electronic searches of MEDLINE and PsycInfo to June 2013 to identify primary studies evaluating patient expectations about recovery in any clinical condition. Reviewers screened titles and abstracts of identified citations, screened full text of potentially eligible studies, and extracted data from all eligible studies. Using the results from the review and input from content experts (psychologists, occupational therapists, methodologists and insurance administrators), we developed items for an instrument assessing recovery expectations in individuals who are receiving disability benefits secondary to a mental health disorders.

Results

Of 12,599 unique citations, 43 studies were eligible. Studies reported on 12 different measurements and 30 individual items assessing expectations of recovery that evaluated an association with a measure of recovery. Seventy-three percent (n=11) of studies using a formal measure reported some measurement properties with 4 reporting an assessment of both reliability and validity. Fourteen (33%) studies assessed the association of expectations about recovery with return to work. We developed a 26-item instrument that will be presented at WDPI 2014.

Conclusions

Only one-third of all articles assessing recovery expectations used a formally developed measure. Of these measures, only a quarter reported both indicators of the quality of measuring an instrument—validity and reliability. Our instrument will aim to assess limitations of existing measures through formal testing and validation.

Presentation 2: Returning to Work Following Low Back Pain: A Model of Psychosocial Factors

Presented by: Elyssa Besen

Authors

Besen E1, Young AE1, Shaw WS1

  1. Center for Disability Research, Liberty Mutual Research Institute for Safety, USA

Abstract

Background

Low back pain (LBP) is one of the leading causes of work disability, and psychosocial factors are associated with returning to work after an episode of LBP. However, the complex and overlapping effects between psychosocial variables have been difficult to assess using traditional linear modeling techniques. The aim of this paper is to develop and test a model of direct and indirect relationships among psychosocial predictors of return-to-work (RTW) outcomes following the onset of LBP. By exploring the potential for indirect, as well as direct relationships with RTW outcomes, we hope to better understand the RTW process and why pain does not always directly lead to outcomes.

Methods

Secondary analysis of a larger study of adults seeking treatment for work-related back pain with recent onset. In total, 241 participants who completed a baseline survey, a short follow-up survey, and a longer follow-up survey after 3 months were included in our analyses. The participants were required to have LBP with onset of less than 14 days, be 18 years or older, and be fluent in English or Spanish. The analyses utilized structural equation models to test the direct and indirect relationships among the variables and RTW outcomes at 3 months.

Results

Our results indicated a good fit for our model (χ2=69.59, df=45, p<.05; RMSEA=.05; CFI=.95; WRMR=.61). Pain, catastrophizing, fear-avoidance beliefs, organizational support, and RTW confidence were all found to have indirect relationships with the outcomes. RTW confidence and RTW expectations were found to have direct relationship with the outcomes.

Conclusions

The process of returning to work after an episode of LBP is a complex process involving many interrelated factors. The experience of pain alone does not directly lead to work disability. Understanding the relationships among critical factors in the RTW process may be important for the treatment and rehabilitation of those with LBP. Results suggest that if injured workers are struggling with fear avoidance, pain catastrophizing and confidence issues, they might benefit from the application of CBT techniques.

Presentation 3: What leads to the expectation to return to work? Insights from a social-cognitive decision making model of future work behaviour.

Presented by: Debra A Dunstan

Authors

Dunstan DA1, Meade Covic T1, Tyson GA1

  1. School of Behavioural, Cognitive and Social Sciences, University of New England, Armidale
  2. School of Psychology, University of Western Sydney, Sydney
  3. School of Psychology, Charles Sturt University, Bathurst, AUSTRALIA

Abstract

Background

The Theory of Planned Behaviour (TPB) is a social-cognitive decision making model that suggests an individual’s intention or expectation to perform a behaviour is the immediate precursor of that behaviour and results from the combined effect of three independent influences. These are: Attitude (the net outcome of positive and negative appraisals of the act); Subject Norm (the net social pressure from important others); and, Perceived Behavioural Control (the degree of challenge associated with performing the behaviour). The aim of this study was to use a TPB model of return-to-work (RTW) behaviour to identify the antecedents of future work expectations in employees with a compensable musculoskeletal condition.

Methods

Standardised procedures were used to construct a TPB model and associated questionnaire to measure the target behaviour “working or continuing to work in three months time”. Participants were Australian injured workers (N = 174), mean age = 43.7 years, mean time since last worked = 9.94 months, mean pain severity (0-10) = 5.86, 53.2% male, 48.1% back injury, 34.2% unskilled. A pilot group (n = 16), plus 3 experts, served as the developmental sample to generate items for the direct and indirect (belief-based) measures of the model’s components. A validation sample (n = 158) completed the questionnaire.

Results

The model met standard psychometric requirements. Attitude, Subjective Norm and Perceived Behavioural Control explained 76% of the variance in the intention or expectation to be working in three months time (R2 = .76, p < .001). The influencing beliefs with the highest associated factor loadings per component were: for ‘Attitude’ (from 8 advantages or disadvantages of working) – increased pain (r = .85); fear of re-injury (r = .85); social contact (r = .85); and, gaining respect and acceptance (r = .84); ‘Subjective Norm’ (from 6 referents) - the opinion of co-workers (r = .80), friends (r = .80) and treating doctor (r = .79); and ‘Perceived Behavioural Control’ (from 9 inhibitors or facilitators of working) – restricted physical capacity (r = .84), pain (r =.80), co-worker support (r = .88) and employer support (r = .86).

Conclusions

This study demonstrated that the TPB is a viable theoretical framework for conceptualizing and understanding the factors influencing the future work expectations of injured employees. The results suggest a range of biopsychosocial issues combine to produce expectations, the strongest influences being: social aspects of work, communication from the treating doctor, co-worker support and pain-related disability.

Presentation 4: What do people take into consideration when they answer questions about their return-to-work expectations?

Presented by: Amanda Ellen Young

Authors

Young A1, Choi Y1, Woiszwillo MJ1

  1. Center for Disability Research, Liberty Mutual Research Institute for Safety, USA

Abstract

Background

Workers’ own expectations for return to work (RTW) have been found to be one of the best predictors of future work status, but there is a limited understanding of why people expect what they do. Using a qualitative methodology (focus groups), this study specifically asked what people take into consideration when forming expectations for return to work.

Methods

34 people (8 women, 26 men) currently off work due to a musculoskeletal condition were recruited to participate in one of 14 two-hour focus groups conducted at our research facility between February and August 2013. At the start of each focus group, each participant completed an individual questionnaire about 1) whether they expect to return to work, 2) the approximate time frame for when they expect to do so, and 3) the factors they considered in forming those expectations. Next, each participant briefly introduced themselves and presented their responses. After that, the influences participants listed were discussed and reflected upon by the group. Focus group audio recordings were fully transcribed and subject to content analysis, which was assisted with the use of NVivo 10.

Results

Participants were 25 to 65 years old (M=45, SD=12.6) and had been out of work for 3 months or less due to their injury. At the time of participating in the focus group all reported expecting to return to work, with the most commonly expected time to RTW being approximately weeks (M = 47 days, Range = 1 day-6 months). When asked to list the things they took into consideration when formulating their answer, most participants listed 4 or 5 factors (Range = 2-14). Generally, participants listed factors such as physical health (e.g., recovery, healing) and financial concerns (e.g., bills to pay) on the questionnaires, but the group discussions revealed a far richer picture. Analysis of the group discussions indicated that many more factors were considered. Findings suggest that when formulating RTW expectations, workers reference components of themselves, as well as elements of their disability management, work, social, economic, and physical contexts. Analysis also indicated that interactions with elements influenced expectations. More specifically, thoughts about, desire and need for, feelings towards, access to, and behavioral exchanges were often spoken about when explaining RTW predictions. It was also found that some elements can influence expectations in contrasting ways. For example, peers were said to exert both positive and negative influence (i.e., “you should be working” vs. “milk the system”).

Conclusions

Indications are that many of the variables that people spoke about were amenable to intervention, suggesting that more can be done to assist workers progress more quickly and confidently through the process of returning to work.