Craven, Kristelle
(2025)
Application of intervention-mapping to co-design and develop a digital, self-guided Return-to-Work Toolkit for stroke survivors and employers.
PhD thesis, University of Nottingham.
Abstract
Background: Stroke incidence is rising among working-age people, leading to long-term disabilities that hinder employment. Due to rising economic inactivity rates, helping people with long-term sickness to return to work (RTW) is now a UK government priority. Ongoing employer support is crucial for ensuring sustainable RTW. However, employers lack the confidence, skills, and knowledge required. Vocational rehabilitation (VR) (anything that helps people with health problems to remain at or return to and stay in work) is often unavailable or inadequate for meeting employers’ and stroke survivors’ needs. Digital, self-guided interventions may increase accessibility and scalability of VR and support the National Health Service’s plans for increased self-management of care by digital means. Literature searches identified self-guided, digital RTW interventions relating to conditions, injuries, or surgery unrelated to stroke. These interventions demonstrated promising results for usefulness, acceptability, effectiveness, and value for money. A gap was identified for a digital, self-guided toolkit to ensure sustainable RTW post-stroke.
Aims: 1) Assess employers’ needs for supporting stroke survivors to RTW, 2) Apply theory- and evidence-based approaches to describe the toolkit’s change mechanisms and implementation strategies, 3) Co-design a toolkit prototype to improve employers’ support for stroke survivors.
Methodology: Intervention-mapping (IM) guided development of the Toolkit for Transitioning to Employment After stroke through Mutual support (TTEAM). The needs assessment (IM step 1) was conducted in two parts. Firstly, a qualitative systematic review explored factors influencing employers’ RTW support for employees with acquired brain injuries and/or mental illness. Findings were synthesised thematically. Secondly, a mixed-methods study explored factors influencing employers’ RTW support for stroke survivors (employer interviews), and described frequency and distribution of employer-related barriers (e.g., stroke knowledge), and their relationships with employers’ demographic characteristics (employer survey). Findings were triangulated with review findings. Three online employer workshops and three advisory group meetings were conducted to aid decisions on TTEAM’s goal, content, and design (IM steps 2-4), and selection of implementation strategies.
Key findings: Across the systematic review (25 studies), employer survey (n=50), and employer interviews (n=7), factors influencing employers’ RTW support included: stroke survivors’ disclosure of stroke-related limitations, employers’ role awareness and communication skills, and where available, information provision from healthcare professionals. From this, it was suggested employers need education on stroke and their RTW-related responsibilities, and guidance on open communication (including finding out stroke survivors’ work abilities and support needs). Employers in any size of organisation may benefit from TTEAM. The needs assessment, employer workshops (n=12), and advisory group meetings (n=20, involving various stakeholders) informed the development of TTEAM, comprising two eLearning packages on Xerte with theory- and evidence-based content for: a) stroke survivors and b) employers. Prototype review by advisory group members (n=15) suggested TTEAM is empowering, offering key information and practical tools. Various implementation strategies were selected, including a user network with peer mentoring to support users in implementation and application of TTEAM.
Conclusion: TTEAM’s dual focus on employers and stroke survivors is novel and supported by theory and research evidence. Further prototype review and refinement are needed prior to feasibility testing. Engagement with potential users and others, such as implementation science experts, with diverse occupational industry/roles, geographical locations, languages, cultures, ethnicities, and areas of expertise is needed to inform refinement of TTEAM, and guide plans for evaluating its effectiveness, cost-effectiveness, and implementation. By increasing access to VR support and reducing demand on services, TTEAM may enhance stroke survivors’ health and wellbeing, upskill users in planning and managing a sustainable RTW, improve workforce sustainability, reduce costs, and contribute to UK economic growth.
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