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Philosophiae Doctor - PhD / Background: Stroke is acknowledged globally and among Nigerian rehabilitation researchers as a public health problem that leave half of its survivors with significant neurological deficits. The attendant sequelae of stroke affects the functional ability, limits activity performance and participation of stroke survivors within the community. The inability to re-establish pre-existing roles after stroke further poses additional challenges on the society, friends and families of the stroke survivor with regards to cost and burden of care. Although stroke disrupt the career pathway of working age survivors briefly, recurrently or permanently; a systematic pathway that facilitates job placement and retention at work for stroke survivors could reduce the devastation and burden caused by unemployment following stroke. As this vocational rehabilitation pathway and programme is currently unavailable for stroke survivors, this study aimed to design a RTW intervention programme that could facilitate the work re-entry for stroke survivors in the state of Osun, Nigeria. Method: The study utilized a multi-phase mixed method research design that was guided by the Intervention Mapping (IM) framework to achieve its objectives. This consisted of three iterative phases that informed one another with the findings culminating into the developed return to work programme for stroke survivors in Osun State. Phase one used a convergent mixed method parallel approach to obtain baseline information on the RTW process, the impairments, activity limitation, and the participation restrictions experienced by stroke survivors in Osun state, Nigeria in two distinct stages that involved a cross-sectional survey and qualitative interviews. The cross sectional survey administered questionnaires that included the Work Rehabilitation Questionnaire, the International Classification of Functioning, Disability and Health (ICF) Brief Core Sets for vocational rehabilitation (VR) and the Work Impact Questionnaire (WIQ) using the face to face method. Descriptive statistics such as measure of central tendencies and frequencies as well as inferential statistics such as logistic regression analysis were performed on the questionnaire data. The qualitative study involved concept mapping using in-depth interviews with stroke survivors who have and those that have not RTW. The transcripts from the in-depth interviews were analysed using the thematic content method. Phase two entailed a scoping review of literature that reported on interventions aimed at facilitating RTW of stroke survivors. The last phase of the study involved a Delphi study with experts in the field of stroke and vocational rehabilitation. The Delphi survey was conducted over three rounds with the final draft of the RTW programme emerging at the third round. Results: Two hundred and ten stroke survivors with mean age 52.90±7.92 responded to the quantitative stage of the phase thereby yielding a response rate of 76.36%. Sixty three point eight percent of the respondents had returned to work with half of them in full time employment (32.9%) while 36.2% had not returned to work. The majority of the respondents identified that travel to and from work (43.8%) and access at work (43.3%) had an impact ranging from ‘quite a bit’ to ‘extreme’ on their ability to work on the WIQ. The results from the quantitative stage further showed that more than ten percent of the respondents experienced complete problem in four components of activity and participation domains of the ICF brief core sets for VR and these include remunerative employment (21.4%), acquiring new skills (17.1%), non-remunerative employment (16.7%), as well as acquiring, keeping and terminating jobs (14.3%). Similarly, energy and drive functions (41.9%) and higher level cognitive function (36.2%) were indicated as culminating in moderate to severe problems in more than a third of the respondents while the “performance of complex interpersonal relationship” and “exercise tolerance function” resulted in no or little difficulty for the respondents. The findings from the logistic regression analysis showed that the combination of side of body affected by stroke (left), type of vocational rehabilitation programme, symptoms of stroke, environment, body function impairments as well as activity and participation problems were the factors that predict RTW after stroke. The logistic regression model significantly explained 55.0% to 75.4% of the variance in RTW after stroke and correctly classified 89.0% of all the cases/respondents. Results from the qualitative stage of the first phase suggests the lived experience of returning to work after stroke to have entailed three themes that was represented by a concept map. The first theme revealed that “it was difficult to live with stroke” for the survivor. The second theme revealed that the stroke survivors’ environment could either worsen or lessen the difficulty experience while the third theme highlighted the various issues that directly impacted on the resumption of worker role of the participants. The scoping review phase (phase two) identified that RTW interventions for stroke survivors falls into three core components which includes 1) intervention components that interface with the stroke survivor; 2) intervention components that interfaced with the workplace and; 3) components that describe strategies of implementation. These core components are interventions that could guarantee an effective RTW for strokes survivors when included in a RTW programme. In the third phase which was the concluding phase of the study, 13 experts in the field of stroke and vocational rehabilitation unanimously agreed at the third round of Delphi that the content of RTW programme for stroke survivors should include an assessment phase, work intervention training phase, work test placement phase and clients full participation in worker role phase that will span a 12 week duration. The developed RTW programme, conceptualized as Stroke Return to Work Intervention Programme (SReTWIP) was designed to be individually tailored to meet the need of the stroke survivor and implemented by an interdisciplinary team that will include the OT and PT as key members. Equally, the stroke survivor is expected to be involved in the decision making process throughout the duration of the SReTWIP. And finally, the programme is to be coordinated by a case manager who will be a member of the interdisciplinary team. Conclusion: It can be concluded that 63.9% of stroke survivors in Osun State, Nigeria return to work. Problems pertaining to lack of energy and drive functioning; higher level cognitive functioning; acquiring new skills; handling stress and psychosocial demands; travel to and from work and access were the common body impairments and problems with activities and participation restrictions that the stroke survivors encountered. Similarly, the study concludes that a multi-faceted programme, the SReTWIP, comprising of four interconnected phases of interventions that targets multiple factors such as personal and environment factors influencing work resumption is likely to be more effective in facilitating quick RTW after stroke.

Magister Scientiae (Occupational Therapy) - MSc(OT) / Individuals diagnosed with stroke particularly in rural communities have a poor return to work rate. Vocational rehabilitation has been used as an intervention strategy with various types of clients with disability or injury in order to improve their work skills. The aim of the proposed study is to describe the experiences and perceptions of individuals diagnosed with stroke about the usefulness of the Model of Occupational Self Efficacy in assisting them in returning to their worker role particularly in a rural setting. Eight participants were purposively selected from the data base of a local hospital and semi structured interviews were conducted with the participants until saturation occurred. Furthermore, two focus groups were conducted with eight participants. A key informant was also interviewed to assist the researcher with a different perspective and to avoid bias. The data was analysed by means of thematic analysis into codes, categories and themes. Trustworthiness was ensured by means of credibility, applicability, transferability and conformability. Informed consent and confidentiality was ensured. Permission was obtained from the UWC research committee and from the Department of Health. Four themes were merged from the findings: Theme one: Obstacles which affects the return to work of CVA Participants in a rural community. Theme two: Establishing a strong belief in functional ability through occupation. Theme three: Adaptation strategies that enhances the work participation of stroke survivors in a rural community. Finally Theme four: The MOOSE enables transition to the worker role in a rural context. The findings revealed that the participants experienced a loss of their former self thus affecting their worker identity as they were no longer able to experience the gratification of fulfilling their worker role. This was due to the participants not being aware of the return to work options that they had. After the stroke the participants battled with not only overcoming their condition but also the stigma which the community and their employers had of stroke. Overcoming the stroke event and returning to work required that potential barriers and facilitators be identified by the participants and the researcher. The study also identified adaptation strategies that the participants utilised in order to overcome the barriers and assist the participants to have a smoother transition into the workplace. In conclusion the findings of the study revealed that the participants suffer a loss of their former abilities and undergo a loss of their self-esteem. As a result of the loss, participants struggled to return to work not only due to their loss of abilities but also their lack of knowledge regarding return to work and stroke. The findings indicated that there should be more education regarding the stroke that needs to be conducted in communities via media such as local newspapers, local radio stations, clinics and hospitals. The findings of the study may assist Occupational Therapy practitioners to improve services in a rural community for stroke survivors and improve the facilitation of the return to work process after stroke. The MOOSE facilitates motivation for participants to regain their self-esteem and thus move forward to resume a worker role. / 2020-08-31