J Occup Rehabil (2007) 17:279288

DOI 10.1007/s10926-007-9075-2
ORIGINAL PAPER

Psychosocial Aspects of Injured Workers Returning

to Work (RTW) in Hong Kong

Cecilia WP Li-Tsang Henky HK Chan CS Lam

Karen YL Lo-Hui Chetwyn CH Chan

Published online: 30 March 2007

C Springer Science+Business Media, LLC 2007

Abstract Introduction: This study was designed to explore the psychosocial aspects of injured
workers, their self-perceived capacity and how these factors influence their success in Return
To Work (RTW). Method: Seventy-five subjects were recruited from the Hong Kong Workers
Health Centre and were assessed on three occasions consisting of interviews and four self-rated
instruments including the Chinese Lams Assessment of Employment Readiness (C-LASER),
the SF-36 health survey, the Chinese State Trait and the Anxiety Inventory (C-STAI). Results:
Results showed that the contemplation and pre-contemplation sub-scores of C-LASER appeared
to be the determining factors in predicting subjects return-to-work status. Subjects who were
more ready for action (the Actioners) were found to have significantly higher confidence and
advocacy in job seeking than the Pre-Contemplators. Their employment readiness was shown to
be affected by psychosocial factors such as perceived functioning and bodily pain, Discussion:
From this study, the injured workers employment readiness appeared to associate with their
RTW outcomes. Further studies would be needed to find out how the employment readiness of
injured workers could be enhanced.

Keywords Injured workers . Employment readiness . Psychosocial factors . Return-to-work

(RTW)

W. P. C. Li-Tsang H. K. H. Chan
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, HK, China

C. S. Lam
Institute of Psychology, Illinois Institute of Technology, Chicago, IL, USA

Y. L. K. Lo-Hui
Hong Kong Workers Health Centre, HK, China

W. P. C. Li-Tsang (
)
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, HK, China
e-mail: rscecili@inet.polyu.edu.hk

C. C. H. Chan
Ergonomics and Human Performance Laboratory, Department of Rehabilitation Sciences,
The Hong Kong Polytechnic University, HK, China
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Introduction

Work-related injuries produce both direct and indirect costs to clients and society, including
compensation, loss of working days, costs of hiring and training new employees or temporary
workers, loss of profits, increased overhead cost during work interruption, decreased employee
morale and efficiency [1]. Occupational rehabilitation has become one of the important services
offered to injured workers to assist them to return-to-work [2].
In Hong Kong, conventional occupational rehabilitation services are carried out in large hos-
pitals, which usually include, functional capacity evaluation, general strengthening exercises,
progressive work hardening and work conditioning program, job analyses and ergonomic mod-
ification and education on proper body mechanics [3]. However, despite the vigorous physical
training, work hardening and conditioning, some injured workers still failed to return-to-work.
The management of the psychosocial aspects of disability and the adjustment of workers to-
wards the disabilities are often missed in our local rehabilitation settings though previous studies
conducted in western countries have shown its effects towards successful employment outcomes
[4, 5].
Previous studies reviewed that most of the vocational rehabilitation programs put less focus on
the psychosocial management, thus leading to less effective interventions. It has been highlighted
in the literature that the roles of workers attitude, motivation and feelings of shame have been
regarded as obstacles to return to work (RTW) by employers or stakeholders. More research is
needed in order to elucidate further how these variables might impact in work disability [4].
Different studies have tried to identify the psychosocial factors that influence the injured
workers abilities to RTW. The most common factors include self-perceived general health status
[6] and adjustment problems following the acquired disabilities [7]. Other factors proposed by
Sullivan and his colleagues include job stress and outside conflicts with co-workers [4]. Research
is needed to explore interactions among different domains of psychosocial risk factors in relation
to RTW outcomes.
The stages of change model proposed by Prochaska et al. [8] can be used as a theoretical
framework to look at the structure of peoples intention to change. Provides a schema of the stages
of changes from Pre-contemplation, Contemplation, Preparation, and Action to Maintenance
stage. The parallel model for stages of work readiness proposed by Lam [9] and the Readiness for
Change Model to the Behavior of Returning to Work proposed by Franche and Krause [10] later
provided more specific insight into RTW readiness of injured workers. The model highlighted
the importance of identifing the stage of employment readiness from the Pre-contemplation stage
(not ready to return to work) to the Contemplation stage (ready to return to work) and Action
stage (actively searching for jobs). Through a systematic evaluation questionnaire, a workers
employment readiness will be identified and interventions can then be more specific to focus on
individual needs. It was reported that these workers employment readiness was often affected
by various psychosocial factors [9] and if these factors were addressed, then their success rate
to RTW will be improved.
Based on the above models, it can be explained that workers at the Pre-contemplation stage
may not show interest in working and they do not consider working as part of their life. Some
might still feel that their body functions were affected by the previous injuries and that they still
consider themselves not fit for work. Some might still have chronic pain arising from the injured
body parts. Workers at the Contemplation stage do consider the importance of work as part of
their life and they would like to resume this work role despite their previous injuries. However,
they still did not take action. Some might find it difficult to return to previous work thinking
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that they might be reinjured. Some would like to seek for a new job but do not know the ways
of searching for jobs to find one that suits them. Workers at the action stage are ready for job
placement and they are actively involved in job seeking and job interviews [9]. The stages of
change model could help the rehabilitation professionals to identify the employment readiness of
injured workers such that appropriate interventions could be provided accordingly. For example,
if the worker was still in the Pre-contemplation stage, they might need greater understanding of
their body function, pain and stress management skills so they can cope with the residual pain
or weakness due to previous work injuries. Individual counseling and group therapy focusing on
coping mechanisms and stress management skills would be effective to alleviate their anxiety.
Thus, they could be more ready to RTW. A workers readiness on seeking re-employment was
believed to have a potential contribution to his/her return-to-work.
The purpose of this study was to explore the employment readiness of injured workers who
were on long term sick leave using the C-LASER and to find out the relationships among the
stage of employment readiness and various psychosocial factors, namely, the self perceived health
status [measured by Short Form-36, the Chinese state trait anxiety Inventory (C-STAI)], the self
perceived physical capacity [measured by Loma Linda University Medical Centre (LLUMC)
Activity Sort and Spinal Function Sort (SFS)].

Methodology

Sampling

A total of 75 subjects were recruited using a convenience sampling method from one of the local
workers health centers. All subjects had previously participated in conventional rehabilitation
services but were still unable to return to their previous work. They were aged between 20 to
65 years, injured at work physically or with repetitive strain injuries (RSI) within the past three
years, and had difficulties to RTW. Those with brain injuries and severe spinal injuries were
excluded in this study due to their limitations in responding to the outcome measures.

Data collection

A comprehensive assessment was conducted on all subjects at three different occasions. The
first assessment was conducted before they joined the RTW Program organized by the centre in
order to capture subjects baseline of their self-rated psychosocial status. The second assessment
was conducted after subjects completed the training session of the program in order to find
out if there was any change on psychosocial status after the training. The third assessment was
conducted after subjects had completed both the training session and the placement session of
Return-to-Work Program in order to capture any change after subjects had actually engaged
in job seeking. In this study, it was assumed that the training sessions of the RTW program
would help to improve the work readiness of the workers from the Pre-contemplation to the
Contemplation stage and that the placement sessions would help to facilitate them to get to
the action stage. By comparing the various factors among the three different occasions, it was
expected to identify the same factors which might affect their employment readiness according
to the stage of training, thus leading to success or failure to RTW throughout the time series.
The assessment consisted of an interview, together with four self-rated instruments including
Spinal Function Sort (SFS), Loma Linda University Medical Centre Activity Sort (LLUMC),
Chinese Lams Assessment of Stages of Employment Readiness (C-LASER), Chinese State
Trait Inventory (C-STAI) and Short Form 36 (SF-36) to be completed by the subjects. These
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tools were selected based on previous studies conducted on evaluation of workers physical
and psychological status after injury [11]. The interview was to collect subjects personal data
including previous job history, family status, etc. The whole assessment procedures took around
60 minutes to complete. Subjects employment status were recorded within 3 months after the
third assessment was conducted.

Instrumentation

Spinal function sort (SFS)

Perceived physical capacity was assessed using Spinal Function Sort (SFS) [12]. This scale was
developed to quantify the disabled individuals perception of his or her ability to perform work
tasks that involved the use of the spine in various ways [13]. This type of psychometric testing
can be useful to provide a baseline measure of the individuals perception of function prior to
the onset of symptoms or therapeutic intervention [14].

Loma Linda university medical centre (LLUMC) activity sort

The Loma Linda University Medical Centre (LLUMC) Activity Sort is a self-report assessment,
which is designed to evaluate the extent to which patients perceive their competence in handling
household tasks through manipulating various domestic tools [15].

The Chinese Lams assessment of stages of employment readiness (C-LASER)

Workers readiness to work was assessed using the Chinese Lams Assessment of Stages of
Employment Readiness (C-LASER). It was designed based on the Stages of Change model [8]
and the Parallel Model for Stages of Work Readiness [9]. The three stages of changes as described
by Lam [9] were included, namely Pre-contemplation, Contemplation, and Action. Previous
studies showed that injured workers with high sub-scores on Contemplation and Action stages
had higher readiness on job seeking than those with higher sub-scores on Pre-contemplation
stage [16].

The Chinese State Trait Inventory (C-STAI)

Anxiety level was assessed using the state score of the C-STAI as it was found to have strong
correlation with other measures of psychological well-being [17]. The C-STAI was tested in
Hong Kong and found to be highly reliable for assessing local subjects [18].

The short form 36 (SF-36)

Perceived general health status was assessed using SF-36. This scale is consisted of 36 items,
capturing most of the important concepts of health-related quality of life in which the translated
Chinese version was found to be equivalent in concept to the original version [19]. Subjects
successful employment within 3 months after the third assessment was recorded.

Data analysis

Stepwise logistic regressions were conducted to identify the predicting variables with sub-
jects return-to-work rate in each occasion. Cluster analysis with Wards method was
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used to differentiate subjects based on their C-LASER factor sub-scores in each occasion. Mul-
tivariate analysis was used to compare subjects characteristics, factor sub-scores of the SF-36,
the C-LASER and their scoring on particular instruments based on results of cluster analysis.
Univariate analysis was further conducted to analyze the scores on particular instruments.

Results

Factors contributing to success of return-to-work

Stepwise regression analysis was conducted on each assessment session. Results from the first
assessment showed a model with a correct classification rate of 73.0%. The variables retained
in the model were factor 1 sub-score (Contemplation and Action stages), social functioning and
role emotional of SF-36. Subjects with higher scores on above items would have higher RTW
rate than those with lower scores. The logistic regression for the second assessment showed
a model with a correct classification of 66.7%. Factor 1 sub-score (Contemplation and Action
stages) was retained in the model. Subjects with higher scores on factor 1 would have higher
RTW rate than those with lower scores. A logistic regression for the third assessment showed a
model with a correct classification of 65.3%. Factor 1 sub-score (The Actioners) and LLUMC
were retained in the model. Subjects with better self-rated factor 1 sub-score and LLUMC would
have higher RTW rate than those with lower scores (Table 1).
Cluster analysis with Wards method was used to differentiate subjects into different clusters
based on their C-LASER factor sub-scores in three assessment occasions separately. Results
suggested two-cluster solutions basing on the factor sub-scores in all three assessment occasions.

The C-LASER sub-scores between the two clusters of subjects

Multivariate analysis of variance was then conducted to compare the differences in factor
sub-scores between the two clusters. Significant group effects were identified of which
subjects classified under cluster 1 had significantly higher sub-scores on factor 1 with items
representing\Contemplation and Action stages (p-value < 0.001), while they had lower
sub-scores on factor 2 than their cluster 2 counterpart in all three assessment occasions

Table 1 Stepwise logistic regression for predicting variables on return-to-work rate

under different assessment occasions

Assessment occasion B SE p-value

1st assessment
SF-36: Role emotional 0.964 0.303 0.001
SF-36: Social functioning 0.671 0.224 0.003
C-LASER factor 1 (Cont. & Action) 0.166 0.085 0.05
Constant 4.746 2.496 0.057
2nd assessment
C-LASER factor 1 (Cont. & Action) 0.131 0.062 0.034
Constant 4.059 1.978 0.040
3rd assessment
C-LASER factor 2 (Pre-Cont.) 0.210 0.086 0.015
LLUMC 0.012 0.005 0.017
Constant 3.669 1.214 0.003

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Table 2 Comparison of C-LASER factor sub-scores and return-to-work rate by factor sub-scores under different
assessment occasions as differentiated by cluster analysis

Assessment occasion 1st occasion 2nd occasion 3rd occasion

Multivariate analysis of C-LASER factor sub-scores

f-value 57.91 96.36 52.42
p-value <0.001 <0.001 <0.001
Return-to-work within 6 months after 1st assessment occasion
Return-to-work rate of Cluster 1 65.2% 73.7% 57.4%
Return-to-work rate of Cluster 2 48.1% 46.4% 42.9%
Chi-square p-value 0.17 0.04 0.26

(Table 2). Subjects in cluster 1 had significantly higher RTW rate (57.4%73.7%), as recorded
within 6 months after the first assessment, when compared to that of the cluster 2 in the second
assessment occasion (42.9%48.19%).

Comparison between different factors and C-LASER factor sub-scores

Multivariate analysis of variance was then conducted to compare the differences in SFS, LLUMC,
C-STAI, and SF-36 sub-scores between the two clusters on three assessment occasions, which
was used to identify possible factors leading to success or failure to return-to-work throughout the
time series. Significant group effects were identified on the first (F[12,62] = 4.32, p < 0.001)
and third (F[12,62] = 2.30, p = 0.02) assessment occasions, while marginal group effect
was identified on the second assessment occasion (F[12,62] = 1.56, p = 0.13). In general,
subjects who were classified under cluster 1 (the Actioners) had higher SFS and SF-36 sub-scores
but lower LLUMC and C-STAI sub-scores than those under cluster 2 (the Pre-Contemplators)
(Table 3).
For the first assessment, further univariate analysis using Bonferronis correction for ad-
justment of type I error (alpha = 0.05/12 = 0.004) revealed significant differences in role
physical (F[1,72] = 8.99, p = 0.004), bodily pain (F[1,72] = 16.46, p < 0.001), vitality
(F[1,72] = 14.96, p < 0.001) and social functioning (F[1,72] = 10.59, p = 0.002) sub-scores
of SF-36 between the two cluster groups. The scores of the Actioners (cluster I) were higher than
the scores of the Pre-Contemplators (cluster II). No significant differences were revealed in the
demographic characteristics between the two cluster groups such as sex (chi-square, p = 0.52),
age (F[1,71] = 2.77, p = 0.10), educational level (chi-square, p = 0.73) and types of injury
(chi-square, p = 0.51).
For the second assessment, further univariate analysis using Bonferronis correction for ad-
justment of type I error (alpha = 0.05/12 = 0.0041) revealed significant differences in physical
functioning (F[1,73] = 10.57, p = 0.002) and physical role (F[1,73] = 12.35, p = 0.001) sub-
scores of SF-36 between the two cluster groups. The scores of the Actioners (cluster I)
were higher than the scores of the Pre-Contemplators (cluster II). No significant differences
were revealed in the demographic characteristics between the two cluster groups such as sex
(chi-square, p = 0.75), age (F[1,71] = 0.96, p = 0.33), educational level (chi-square, p = 0.69)
and types of injury (chi-square, p = 0.55).
For the third assessment, further univariate analysis using Bonferronis correction for
adjustment of type I error (alpha = 0.05/12 = 0.004) revealed significant differences in
physical functioning (F[1,73] = 9.06, p = 0.004), role physical (F[1,73] = 12.19, p = 0.001)
and emotional role (F[1,73] = 18.65, p < 0.001), and sub-scores of SF-36 between the two
cluster groups in which the scores of the Actioners (cluster I) was higher than the scores of
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 Table 3 Comparison between different factors and C-LASER factor sub-scores

Two Cluster Group

1st assessment occasion 2nd assessment occasion 3rd assessment occasion
(F-value/p-value) (F-value/p-value) (F-value/p-value)

Bodily pain 16.46 < 0.001 / / / /

Vitality 14.96 < 0.001 / / / /
Social functioning 10.59 0.002 / / / /
Role physical 8.99 0.004 12.35 0.001 12.19 0.001
Physical functioning / / 10.57 0.002 9.06 0.004
Emotional Role / / / / 18.65
J Occup Rehabil (2007) 17:279288

<0.001
p-value
Sex 0.52 0.75 0.46
Age 0.10 0.33 0.64
Educational level 0.73 0.69 0.66
Types of injury 0.51 0.55 0.49

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the Pre-Contemplators (cluster II). No significant differences were revealed in the demographic
characteristics between the two cluster groups such as sex (chi-square, p = 0.46), age
(F[1,71] = 0.23, p = 0.64), educational level (chi-square, p = 0.66) and types of injury
(chi-square, p = 0.49).

Discussion

This study explored the psychosocial aspects of injured workers RTW in terms of their readiness
and their psychosocial characteristics. Results of this study suggested that C-LASER factor
sub-scores of the injured workers which helped to differentiate the Actioners and the Pre-
Contemplators, appeared to be important factors associated with workers success to RTW.
On the other hand, subjects readiness towards RTW were associated with perceived function
(LLUMC), bodily pain (SF-36) and their self perception on the health status (as measured by
SF-36s). Those subjects in cluster I (the Actioners) showed higher scores on these factors while
those subjects in cluster II (the Pre-Contemplators) appeared to show lower scores on these
factors.
The Actioners retained from logistic regression on all three assessment occasions indicated
that this was an important variable in predicting their employment outcomes. This was further
confirmed by cluster analysis that there were differences among clusters being differentiated
by means of their factor 1 sub-score. Subjects with higher factor 1 sub-score (higher scores
on Contemplation and Action stages) had higher tendency towards successful employment.
Subjects who had higher factor 1 sub-score (the Actioners), who were regarded as ready for
action group, were found to have significantly higher perceived physical function, less pain
and higher social functioning. Thus, they appeared to be more confident [16]. Their chances of
employment would then increase as their frequency of job seeking behavior increased as well as
their demonstration of higher self confidence during interview.
In order to further investigate the contribution of factor 1 sub-score on subjects psychosocial
readiness towards progression of stages of RTW, Franche and Krauses model of readiness
for RTW following injury or illness [10] had divided the progress into three different aspects:
decisional balance, self-efficacy and process of change. In regard to subjects decisional balance,
they had to weigh the pros and cons of returning to work during the intervention. For example,
subjects would gain income once they had return to work (pros) but on the other hand, they might
have their workers compensation stopped. For those who had higher sub-score in factor 1, they
identified more positive (pros) factors than negative (cons) factors in RTW. In this way, they
could regain their self-esteem, reassure their return of physical capacity and resume their role as
either bread-winner or income generator. For those subjects with higher factor 1 sub-score, they
were found to have higher self-efficacy towards RTW especially in terms of job seeking [16].
Their higher confidence in engaging in RTW could facilitate them to further test their actual
ability. In other words, they were more willing to step-out from an injured-person role into
a working-person role. Finally, in regards to their process of change, they shared their desires,
worries and feelings towards RTW during the process of intervention, and by sharing among
the subjects, they might come up with some possible solutions. This was named by Franche and
Krause as Experiential Change [10]. Subjects had better awareness and had higher intention
to resume employment which prepared them to be more ready in job seeking. However, there
were differences of their intrinsic values on RTW among subjects during the process. Factor
1 sub-score, therefore, would be one of the predictive factors to show the extent of change in
order to actively engage in job seeking. This was further confirmed by the significant differences
in the employment rate on the second assessment which represented the time when subjects
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completed their intensive training sessions they tended to score higher in Factor 1 sub-score
(Actioners), representing higher tendency to Contemplation and Action stages. In addition, with
the alignment of subjects experiential change, they would be actively involved in actual job
seeking activities and a work trials, which was referred as Behavioral Change [10], thus
affecting their successful chance in job seeking.
The C-LASER factor sub-scoreo could be used to discriminate the Actioners and the Pre-
Contemplators in this study. Though the discrimination of Actioners and Pre-Contemplators
appeared to associate with subjects RTW rate, these workers self-perceived physical capacity
and pain seemed to contribute to be the two main factors to discriminate the ready and not-ready
group as shown from the multivariate analysis. Other SF-36 factors such as role emotional and
social functioning also had a positive effect on their employment readiness.
Self-perceived physical capacity was found as one of the primary recovery outcome measures
for subjects with low back pain by Oleske et al. [6]. The relatively low perceived work capacity
was also believed to be related to the high pain intensity [20] as shown from the results. It was
one of the important variables for consideration in the perceived capacity for work-related tasks
[20]. There was a strong need to manage pain not just physiologically, but psychologically and
behaviorally, which might alter cognitive appraisals of pain and loss, and improve coping styles
[21]. According to Melles et al. [22], significant divergence of opinions exists among physicians,
staff and patient expectations of a rehabilitation program. Physicians and patients considered
pain control as the most important objectives in treatment and that it should be one of the most
important goals in the rehabilitation of injured workers.
The concept of secondary loss [21] could plausibly explain the findings related to emotional
role and social functioning. The secondary loss, as defined, is a subsequent loss developed
from its primary loss [21]. For example, an injured worker might have limited career choice
(secondary loss) after the injury (primary loss). Secondary loss could create impact on their
psychological well-being and functioning. Most of the injured workers with chronic pain and
physical limitations might be particularly vulnerable to the rippling effects of the losses of
health and well-being [21]. Secondary loss compounded relationship loss and employment loss
with affective consequence [21]. Relationship loss for subjects with work injury included loss
of the life role as income generator to the family, loss of the social role with colleagues and
employers and even diminished as a person, which happened especially when subjects went
from being relatively autonomous to dependent, from vigorous health to chronic disability and
fatigue, and from social engagement to isolation [21]. Employment loss included partial loss
of earning capacities, loss of potential to find employment due to possible discrimination and
rejection from employers. The employers might feel that there were chances of re-injury for the
same worker [21]. These losses might hinder their process of RTW. Early intervention should
be considered, such as psychosocial education and building-up relationship with employers.
In summary, the workers employment readiness appeared to be strongly associated with the
success of RTW rate. Factors such as perceived physical function, bodily pain and self perception
of general health might contribute to their employment readiness, which therefore, should be
incorporated in future occupational rehabilitation of injured workers. This study was conducted
in three phases with a view to address the changes of these factors in response to the intervention
given to these workers and it reflected a consistent association among the factors identified.
However, in view of the small sample size collected, further study is recommended to find out
the predictors on employment outcomes of these injured workers.

Acknowledgements The authors thank Hong Kong Workers Health Centre for jointly collaboration of this study,
Mr. Yanwen Xu and Mr. Jiaqi Li for their effort on data collection. We would also like to thank all the participants
of this project. This study would not have been possible without their support.
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