Early return to work of injured workers: multidimensional patterns of individual and organizational factors

Safety Science 41 (2003) 277–300 www.elsevier.com/locate/ssci

Early return to work of injured workers: multidimensional patterns of individual and organizational factors Raymond Barila,*, Diane Bertheletteb, Paul Massicottea a

Institut de recherche Robert-Sauve´ en sante´ et en se´curite´ du travail, Montreal, Quebec, Canada Business School of Administration, Universite´ du Que´bec a` Montre´al, Montreal, Quebec, Canada

b

Received 8 July 2002; received in revised form 8 August 2002; accepted 8 August 2002

Abstract The research reported here, part of a larger exploratory project about the factors that may play a role in the implementation of corporate return to work measures, characterized workers having suffered an occupational injury. These workers constitute the target population of a governmental policy designed to favour early return to work. The study population was composed of 13 728 cases of occupational injury. The characteristics of workers, characteristics of injuries and structural characteristics of companies in cases in which return to work measures were present were compared with these same characteristics in cases in which such measures were absent. Using correspondence and ascending hierarchical classification analyses, homogenous groups were identified. Bivariate analysis revealed that the following eight variables were associated with the presence of early return to work measures (i.e. the proportion of cases benefiting from early return to work measures was significantly higher than expected): nature of the injury (inflammation); site of injury (upper limbs and shoulder); CSST assessment category (=100%, i.e. large company); duration of absence (0–44 days and 183–365 days); gender (female); sector (rubber and plastics); relapse (present); and age (30–39 years). The presence or absence of return to work measures was a defining characteristic of five of the seven classes identified by multivariate analysis. The composition of these classes reflects the complex interaction between return to work measures on the one hand and the socio-demographic characteristics of workers, characteristics of injuries, and structural characteristics of companies on the other. # 2002 Elsevier Science Ltd. All rights reserved. Keywords: Return to work; Disability management; Rehabilitation; Injured workers; Modified work

* Corresponding author. 0925-7535/03/$ - see front matter # 2002 Elsevier Science Ltd. All rights reserved. PII: S0925-7535(02)00039-5

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1. Introduction Issues related to the occupational re-integration of workers with functional limitations, and to return to work measures in particular, have attracted the interest of many researchers and practitioners. The development of rehabilitation programs for disabled workers dates back to the 1940s, and, according to Akabas (1986), was in large part driven by unions, particularly the United Mine Workers. Towards the end of World War II, the United Mine Workers learned of several cases in which antibiotics and recent advances in rehabilitation had prolonged the survival of Appalachian miners who had become paralyzed as a result of accidents. This raised hopes that alternatives to bed-rest could be developed for paraplegics. Many workers in the Appalachians followed a rehabilitation program offered by the Institute of Physical Medicine and Rehabilitation of New York during this period. In a study of the program’s process and outcomes conducted in the 1950s, Mary Switzer reported that it improved participants’ physical and occupational function. According to Akabas (1986), these findings resulted in improved care for victims of occupational accidents and encouraged labour unions to strengthen their commitment to occupational reintegration programs. In the United States, the combined weight of social awareness and pressure, legislation prohibiting discrimination against persons with disabilities, and increases in the costs associated with the care and compensation of accident victims, spurred interest in occupational re-integration programs; this was particularly evident in large companies in the late 1980s (Akabas et al., 1992; Pati, 1985; Shrey and Lacerte, 1995; Tate et al., 1986). A series of conferences presented in 1980 in the United States by Aila Jarvikoski of the Rehabilitation Foundation of Helsinki fostered the emergence of a new concept in rehabilitation, namely ‘‘Disability Management’’ (Galvin and Schwartz, 1986). Many position papers and guidelines have been published on this subject, and have identified the factors underlying effective disabilityprevention and rehabilitation programs (Galvin and Schwartz, 1986). More recently, interest has centred on the economic challenges faced by compensation agencies, the effect of competition and market globalization on corporate management practices, and reports that early and safe return to work of victims of back injuries improves their rehabilitation (Dahlen and Wernesson, 1996; Durand et al., 1998; Habeck et al., 1991; Loisel et al., 1997; Morrison, 1993). In Quebec and the rest of Canada, the 1990s saw the development and implementation of policies designed to favour the early return to work of victims of occupational injuries. This article discusses the Quebec policy on early return to work adopted in 1993 by the Commission de la sante´ et de la se´curite´ du travail (CSST, Quebec occupational health and safety commission), the provincial agency responsible for applying occupational health and safety legislation. Although research on occupational re-integration of injured workers is steadily increasing, it is still fair to say that the field is, in some respects, still emerging, particularly since most studies have focussed on the medical management of injured workers. A number of fundamental principles of occupational re-integration and the application of return to work measures have nevertheless gained wide acceptance, and the World Health Organization’s definitions of impairment, disability and handicap (WHO, 1980)

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have stimulated thought on the subject. While the concept of impairment in this context is similar to its meaning in purely medical contexts, the complex post-trauma phenomena associated with occupational injury can only be understood if a wider view, taking into account worker’s social environment, is adopted (Levine and Schieber, 1988). In fact, psychosocial research has revealed that occupational re-integration should be analyzed as a social process which largely exceeds narrowly medical terms of reference (Baril et al., 1994; Daujard, 1996; Truchon and Fillion, 2000). It is now recognized, in part as a result of Fougeyrollas et al.’s (1996) development of a model of handicap development, that the work environment is part of the social environment in which handicaps appear. Return to work measures forming part of an occupational reintegration program are an attempt to prevent the development of handicaps, i.e. the marginalization or social exclusion of workers (Martin and Baril, 1993). Several authors believe that returning victims of occupational accidents or diseases to work as soon as possible is essential to the prevention of disability (Spitzer et al., 1987; Frank et al., 1996). Prolonged work absences may reduce workers’ ability to find productive and significant work that allows them financial independence. It should be borne in mind that despite the recent flurry of publications on the subject, early return to work is a very recent concern, studies of it are still relatively rare, and there remain methodological problems associated with its study (including a strictly biomedical, prediction-oriented approach, fuzzy definitions of return to work, and a lack of models). Early return to work is increasingly seen as a useful expedient under some conditions, for example when appropriate modified duties are available to injured workers. In a recent literature review of modified work and return to work, Krauss et al. (1998, p. 113), concluded: ‘‘Injured workers who are offered modified work return to work about twice as often as those who are not. Similarly, modified work programs cut the number of lost work days in half.’’ However, as Akabas (1986, 1992) noted, it is essential to remember that the point of an occupational re-integration program is to rehabilitate workers as well as return them to work. These principles lie at the heart of the concept of therapeutic return to work (Durand et al., 1998). From a corporate perspective, the long-term effect of therapeutic return to work is the reestablishment of workers’ employability and productivity (Shrey and Lacerte, 1995). Studies on the organizational determinants of the implementation of early return to work programs are extremely rare. Two exploratory Quebec studies have been reported recently, the first examining the factors influencing the case management of workers with musculoskeletal problems in the electrical and electronics industry (Stock et al., 1999), the other analyzing the potential organizational components and determinants of corporate return to work measures (Baril et al., 2000). The only other study specifically examining the organizational determinants of the implementation of early return to work measures was Shoemaker’s study (1989) of the resistance of American companies to such practices. Partial information on the organizational determinants of the implementation of return to work programs is available from six other empirical studies. Five of these were conducted in Canada: two in Quebec (Baril et al., 1994; Le´vesque, 1993), two in Ontario (Butler et al., 1995; Johnson and Baldwin, 1993), and one in British

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Columbia (Wood, 1987). The sixth study was conducted in Australia (Hocking et al., 1993). Two studies (Hocking et al., 1993; Wood, 1987) have evaluated the outcomes of interventions designed to reduce the duration of absence from work following occupational injuries. The Ontario studies attempted to identify factors associated with early and later return to work, but did not take into account the effect of corporate interventions designed to promote early return to work. Baril et al. (1994) explored the determinants of early and later return to work, including the presence of organizational interventions. Finally, Le´vesque’s study (1993) tried to identify the organizational characteristics of firms that might explain the recourse to temporary assignment. No study has succeeded in developing a theoretical framework suitable for the generation of clear hypotheses about the role of organizational characteristics on the implementation of early RTW measures for workers having suffered occupational accidents. The research reported here is part of a larger study aimed at producing such hypotheses. In 1997, 138 708 workers (approximately 5.3% of the Quebec workforce) requested CSST compensation for an occupational accident or disease (CSST, 1998). Most of these requests were associated with a work absence; as described above, prolonged work absences hinder return to work and result in significant human, social and economic costs. In Quebec, the Act Respecting Industrial Accidents and Occupational Diseases, adopted in 1985, prescribes two primary return to work measures: the right to return to one’s former work, and temporary reassignment. In light of this, the CSST recently developed an early return to work policy (CSST, 1993), designed to increase the percentage of workers returning to their former employer following an occupational accident or disease. Injured workers absent from work for more than 45 days constitute the target population for these return to work measures. The concrete manifestation of this policy has been the implementation of a professional service, which identifies temporary or permanent return to work measures in collaboration with workers, worker (union) representatives, employers, and attending physicians. There have been no scientific studies of the characteristics of large populations of injured workers who have been the object of early return to work measures implemented by their employers. The research reported here was undertaken to rectify this situation. Injured workers constituting the target group of the CSST’s early return to work policy were characterized and grouped into typical classes on the basis of the presence or absence of return to work measures. The results are an integral part of a larger research project (incorporating qualitative analysis of data from case studies) whose objective is the formulation of hypotheses concerning the determinants of the implementation of corporate return to work measures (Baril et al., 2000).

2. Methods 2.1. Study population The data for this descriptive study is drawn from the CSST’s administrative database of occupational injuries used to manage events which may hinder return to work.

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To be included in this database, events have to result in (a) work absences of more than 45 days or (b) the company notifying the CSST’s rehabilitation counsellor that the injured worker was benefiting from corporate return to work measures, regardless of the length of work absence. Events resulting in work absences of fewer than 45 days are only included in the database if the injured workers benefited from early RTW measures. Despite this limitation, these cases were included in the study, one of whose objectives was the description of the specific characteristics of this group of workers. The database includes all injuries occurring between January 1994 and March 1997. Data were selected from four regional CSST offices: three in the metropolitan Montreal area and one responsible for the Eastern Townships region. The study population consisted of 13 728 cases of occupational injury. 2.2. Description of variables Cases were classified in terms of the four following groups of variables: (1) workers’ characteristics (gender, age group, occupation, occupational group), (2) injury characteristics (site, nature, presence or absence of relapse, duration of absence), (3) presence of early return to work measures and (4) structural characteristics of the worker’s company at the time of injury (assessment rate, industrial sector). Data on workers’ characteristics and injuries were taken from the CSST’s occupational injury file, data on early return to work was taken from the four regional offices’ databases, and data on the characteristics of the companies was obtained from the CSST’s company database. These variables were grouped into categories and used to identify typical cases of occupational injury associated with the presence or absence of corporate return to work measures. The guiding principles for category formation were: (1) Categories should be meaningful reflections of the probability that return to work measures had been implemented, and (2) The number of categories should be low, in order to optimize the number and interpretation of typical cases. In light of the results of Baril et al. (1994), who noted the presence of considerable differences in the nature and dynamics of occupational re-integration and injury severity among subjects younger than 30 years and at least 50 years old, age was stratified into four categories: 15–29 years, 30–39 years, 40–49 years, and at least 50 years. For the purposes of this study, Baril et al.’s 30–50 years group was divided into two, in order to obtain more homogenous age distributions. Occupational subdivisions were coded using the Canadian Classification and Dictionary of Occupations (Department of Manpower and Immigration, 1971). Excessively small categories were grouped to form classes of acceptable size. The site and nature of injuries were grouped using the Occupational Injuries and Illness Classification System of the United States Bureau of Labor Statistics (1992). The duration of work absence was stratified into six categories: < 44 days, 45–90 days, 91–182 days, 183–365 days, 366–730 days, and > 731 days. The first category corresponds to the theoretical minimum work absence used by the CSST to identify cases which require intervention by their early return to work personnel. The next three categories were devised to adequately represent absences of less than one year

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(the longest period workers from a company employing fewer than 20 workers may be absent and retain the right to return to their positions) and constitute groups of useful size. The last two categories correspond to the longest period workers in larger companies may be absent from work and retain the right to return to their position, and the duration of work absence after which there is no right to return. The CSST codes early return to work measures in its database as follows: temporary reassignment, progressive return, occupational therapy, supernumerary, and internship. Temporary reassignments, sometimes accompanied by progressive return to work, accounted for the majority of measures recorded in the database. In light of this, return to work was treated as a dichotomous variable, and comparisons were performed on the basis of the simple presence and absence of return to work measures. On the basis of the recommendations of the CSST’s Rehabilitation Service, company size was classified as small, medium or large on the basis of CSST assessment category (< 10%, 510% to < 100%, and 100%). The Quebec Industrial Classification System was used to code companies’ economic activities. 2.3. Types of analysis Following descriptive analyses, each categorical variable was subjected to bivariate analysis. For each categorical variable, the distribution of cases over coded values was compared to the expected distribution; the results for cases in which early return to work measures were or were not applied are presented in Figs. 1 and 2, respectively. Statistics were calculated using the chi-squared module of the SAS software package. Categorical variables whose observed value distribution differed significantly from expected were subjected to further bivariate analyses against all the other variables. Finally, multidimensional analyses—correspondence analysis and ascending hierarchical classification analysis (Benze´cri, 1985; Cloutier, 1994; Fenelon, 1981)—were performed using the SPAD.N (portable digital data analysis) system, in order to identify typical homogenous classes, i.e. classes with common characteristics, in the entire population. Comparison of the results of the bivariate and multivariate analyses facilitated interpretation of results.

3. Results This section first presents the results of the descriptive analyses of the distribution of the characteristics of workers, companies, injuries and return to work measures. This is followed by a presentation of the results of the bivariate and multivariate analyses. 3.1. Descriptive population statistics 3.1.1. Characteristics of workers Males accounted for 64.6% of the population. Slightly more than 50% of the cases involved workers younger than 40 years. Most of the cases (54.9%) involved workers in manufacturing or primary resource processing. Of the remainder, 35.7%

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Fig. 1. Variables with a statistically significant association with the presence of early return to work measures. 283

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Fig. 2. Variables with a statistically significant association with the absence of early return to work measures.

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involved workers in the service sector (health, sales, administration, teaching or recreation), and 1.9% involved workers in the agricultural, forestry or mining sectors.1 Manual and mixed-work2 workers accounted for 86.3% of the workers in the population, the remainder (13.7%) performing non-manual work. 3.1.2. Characteristics of companies Most of the cases (56.6%) involved medium-sized companies; small and large companies were present in similar proportions–21% and 22.4%. Almost 52% of cases involved tertiary-sector companies, almost 45% involved the secondary sector and 3% involved the primary sector. 3.1.3. Characteristics of injuries More than 75% of injuries involved the trunk, neck, upper limbs or shoulders. More than half of all injuries were musculoskeletal in nature. Relapses occurred in less than 20% of cases. Approximately 80% of the injuries resulted in a work absence of fewer than 6 months. 3.1.4. Characteristics of return to work measures The quantitative analyses revealed that 21.4% of the cases registered by the four regional CSST offices between January 1994 and March 1997 had benefited from early return to work measures. The CSST database indicates that in almost 90% of cases, early return to work measures took the form of temporary reassignment, occasionally accompanied by progressive return to work. 3.2. Bivariate analyses This section presents the results of the bivariate analyses of the presence or absence of early return to work measures and each of the other variables. The results are divided into two sections. The first section discusses variables with a statistically significantly association with the presence of early return to work measures, while the second discusses variables with a statistically significant association with the absence of early return to work measures. The proportion of cases having benefited from early return to work measures was significantly greater than expected in the following cases: nature of the injury= inflammation; site of injury=upper limbs and shoulder; CSST assessment category=100% (i.e. large companies); duration of absence=0–44 days or 183–365 days; gender=female; sector=rubber and plastics; relapse=present; and age=30–39 years. Groups of significantly interrelated variables were identified by analyzing each of these variables and their association with each of the other variables. This analysis 1

Seven hundred and seventy-seven workers were not classified, primarily because of missing occupational information. In addition, some occupations are under-represented, compared to the global Quebec workforce. This is particularly true of the construction trades, for which none of the three Montreal-area CSST offices collect data. Data from the Eastern Townships CSST office is however representative of that region’s workforce. 2 Non-manual work is a significant component of mixed work (He´bert et al., 1996).

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proved useful in revealing trends (Fig. 1) in the application of early return to work measures. The first group is defined by the nature and site of injury. Workers who suffered inflammation of the upper limbs and shoulders appear to have been the beneficiaries of early return to work measures. Female workers were statistically more likely to suffer inflammation, and there was a significant positive association between open wounds and injuries to the upper limbs and shoulders. The data is inadequate for interpretation of this last association. The second group is defined by the employers’ CSST assessment category and the duration of work absence. Large companies were associated with short work absences, and both these variables are associated with the presence of early return to work measures. It was impossible to determine the direction of the association between short work absences and the presence of early return to work measures. Large company size was associated with the health and social services and health sciences sectors. Finally, female workers were more prevalent in the health and social services and health sciences sectors, as well as in other sectors. These results indicate that the beneficiaries of early return to work measures in this class are female workers who have suffered inflammation of the upper limbs and shoulders, and are employed by large organizations (particularly in the health and social services sector), and that work absences are relatively short (less than 44 days). The proportion of cases not having benefited from early return to work measures was significantly greater than expected in the following cases: CSST assessment category= < 10%, (i.e. small company); occupational group=non-manual; and duration of work absence=45–90 days. The relation between the absence of early return to work measures and the other variables appears more disperse than that observed in the previous case (Fig. 2). However a strong triangular relation exists between the absence of measures, small company size and non-manual work. There is a significant positive association between relatively short work absences (between 45 and 90 days) and the absence of early return to work measures. The duration of work absence in this group is significantly associated with hernias and the absence of relapses. In summary, bivariate analyses indicate that the presence of early return to work measures discriminates between large and small companies.3 The presence of return to work measures is associated with short (0–44 days) and relatively long (183–365 days) work absences, while the absence of return to work measures is associated with relatively short absences4 (45–90 days). Early return to work measures are associated with female workers in large organizations in the health and social ser3 Not only is there a statistically significant positive association (P <0.05) between large company size and the presence of return to work measures, but a significant negative association (P <0.05) also exists between large company size and the absence of such measures. The situation with regard to small companies is precisely reversed (P<0.05). 4 Work absences of 45–90 days exhibited a statistically significant positive association (P <0.05) with the absence of return to work measures, and a significant negative association (P <0.05) with the presence of such measures.

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vices sector, and work absences of 0–44 days. In contrast, companies in which early return to work measures are absent are small and employ predominately female non-manual workers5 (the last two variables being related). Relapse-related clusters can also be observed. Workers suffering relapses were absent from work for prolonged periods (366–730 days) and were the object of return to work measures, while the absence of relapse is associated with relatively short work absences (45–90 days) and the absence of early return to work measures. Inflammation (associated with female workers) of the upper limbs and shoulders is associated with the presence of early return to work measures. Finally, two relatively isolated variables—employment in the rubber and plastics sector, and age between 30 and 39 years—were also associated with the presence of early return to work measures. 3.3. Multivariate analyses The exploratory multivariate analyses presented in this section were undertaken to identify variable clusters associated with either the presence or absence of early return to work measures. It was hoped that this analysis would allow targeting of groups for field interventions and future research, as well as help formulate hypotheses concerning the sources of intra- and inter-organizational variation in the availability of early return to work measures. Using correspondence analysis and ascending hierarchical classification analysis, the entire population was divided into sub-groups or classes, and the descriptive characteristics related to early return to work measures identified (Tables 1–3). The variables which best account for clustering in the entire study population are, in descending order: occupation, economic sector, gender, occupational group, presence or absence of early return to work measures, nature of injury, site of injury, CSST assessment category, duration of work absence, age group, and presence or absence of relapse. The presence or absence of early return to work measures, although never the best discriminating variable, is nevertheless useful, as it is a significant factor in five of the seven classes. The rest of this section presents the attributes of each variable whose occurrence in a class is statistically greater than expected. The absence of early return to work measures was characteristic of three classes (II, V, and VII), representing 37.3% of the study population (Table 1). These classes are typified by: Class II: Manual workers older than 40 years in large companies in the transportation and warehousing sector, with musculoskeletal injuries to the trunk, neck, and to a lesser extent, lower limbs, and work absences of 45–90 days. Class V: Female manual workers younger than 30 years employed in small companies in the service sector (especially in the accommodation and restaurant 5

The non-manual occupational group is significantly associated (P <0.05) with the absence of return to work measures and negatively associated (P <0.05) with the presence of such measures.

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Table 1 Characteristics of the three classes not benefiting from early return to work measures Class II 1222 cases 10.0% of the population Class V 1823 cases 15.0% of the population Class VII 1500 cases 12.3% of the population Inertia: 2.8%a Inertia: 5.4% Inertia: 5.8%

Occupation

Transportation Materials handling Construction

(61.5)b (21.4) (8.8)

Services

(79.9)

Administration, sales Director, teacher

(54.7) (39.3)

Sector

Transportation and warehousing Civil service Food and drink

(59.0)

(50.6)

Civil services

(25.6)

(16.6) (6.6)

Accommodation, restaurant, leisure Others services Civil services Housekeeping Brokerage

(15.6) (11.5) (9.3) (4.7)

Health, social services Wholesale, retail Housekeeping Brokerage

(19.4) (11.3) (11.0) (10.1)

Gender

Male

(91.6)

Female

(37.2)

Female

(57.1)

Occupational group

Manual and mixed

(98.0)

Manuals and mixed

(94.7)

Non-manual

(92.2)

Measures applied

No

(88.2)

No

(81.8)

No

(82.8)

Nature of injury

Muscle trauma Contusion Spinal disorder Hernia

(41.1) (14.9) (8.6) (3.8)

Muscle trauma Bone trauma Contusion

(45.5) (14.9) (10.8)

Bone trauma Other

(15.1) (4.1)

Site of injury

Trunk and neck Lower limbs Multiples sites

(49.7) (22.3) (6.5)

Trunk and neck Lower limbs

(43.0) (22.1)

Lower limbs Multiple sites

(20.3) (8.1)

(continued on next page)

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Variable

Variable

Class II 1222 cases 10.0% of the population Class V 1823 cases 15.0% of the population Class VII 1500 cases 12.3% of the population Inertia: 5.4% Inertia: 5.8% Inertia: 2.8%a

Size (Assessment category) Large (100%)

(39.0)

Small ( 10%)

(48.2)

Small ( 10%) Large (100%)

(29.6) (28.1)

Duration of absence

45–90 days

(39.8)

45–90 days 91–182 days 183–365 days

(39.4) (27.1) (12.7)

183–365 days 366–730 days

(11.9) (6.4)

Age group

40–49 550

(29.3) (29.0)

15–29

(26.2)

No

(82.8)

No

(83.3)

Relapse a b

The inertia is a measure of the homogeneity of the class—the lower the inertia, the more the class is defined by similar characteristics. Percentage of cases in each category. For example, workers with an occupation related to transportation account for 61.5% of the cases in Class II.

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Table 1 (continued)

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Table 2 Characteristics of the two classes benefiting from early return to work measures Class III 2696 cases 22.1% of the population Inertia: 5.4%

Class VI 1436 cases 11.8% of the population Inertia: 3.1%

Occupation

Fabrication, assembly, repair Machine tooling, Secondary

(52.9) (31.8)

Health sciences Services

(80.5) (17.1)

Sector

Leather, textile, garments Metal prod. machinery, transport. equipment Wood, furniture Rubber and plastics Food and drink

(27.7) (18.9) (11.1) (11.0) (7.6)

Health, social services

(93.8)

Female

(76.8)

Gender Occupational group

Manual and mixed

(99.8)

Measures applied

Yes

(27.5)

Yes

(27.4)

Nature of injury

Inflammation Open wound Bone trauma

(34.6) (21.9) (17.4)

Muscle trauma Unspecified pain Spinal disorder

(46.4) (23.6) (9.3)

Site of injury

Upper limbs, shoulders

(88.5)

Trunk and neck Multiple sites

(56.2) (6.3)

Size (Assessment category)

Medium (11–99%)

(67.9)

Large (100%)

(45.5)

Duration of absence

91–182 days 366–730 days

(25.0) (6.1)

0–44 days

(41.1)

Age group

15–29

(23.6)

40–49 550

(31.3) (26.1)

Relapse

Yes

(20.8)

No

(82.9)

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Variable

Table 3 Characteristics of the two class with no influence from early return to work measures Class IV 618 cases 5.1% of the population Inertia: 2.5%

Occupation

Fabric., ass., repair Materials handling Mach. tooling, Secondary

(34.3) (33.6) (23.9)

Agriculture, forestry, mining Mach. tooling, Sec. Construction

(39.8) (26.5) (13.6)

Sector

Leather, text., garm. Metal prod. machinery, transport equipment Wood, furniture Food and drink Housekeeping Rubber and plastics

(21.1) (13.1) (10.0) (8.8) (7.2) (6.7)

Primary Wood, furniture

(63.7) (9.2)

Gender

Male

(80.9)

Male

(96.2)

Occupational group

Manual and mixed

(100.0)

Manual and mixed

(99.5)

Nature of injury

Muscle trauma Unspecified pain Spinal disorder Hernia

(51.2) (14.4) (10.3) (4.9)

Bone trauma Open wound Other Hernia

(27.5) (10.4) (8.4) (4.4)

Site of injury

Trunk and neck

(69.2)

Lower limbs Multiple sites

(25.4) (8.1)

Size (assessment category)

Medium (11–99%)

(73.0)

Large (retrospective) Small ( 10%)

(29.4) (29.0)

Duration of absence

5731 days

(3.4)

Age group

30–39 15–29

(35.4) (22.4)

550

(28.6)

Relapse

Yes

(21.0)

Yes

(22.0)

Measures applied

291

Class I 2893 cases 23.7% of the population Inertia: 5.3%

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Variable

292

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sector), with musculoskeletal injuries to the trunk, neck, and, to a lesser extent, lower limbs, relatively long work absences (up to one year), and no relapses. Class VII: Female non-manual workers in small or large public-sector organizations (teachers), the retail sector (saleswomen) or the finance sector, with injuries to multiple sites, the lower limbs or the bones, work absences of up to 2 years, and no relapses. The presence of early return to work measures was characteristic of two classes (III and VI), representing 33.9% of the population (Table 2). These classes are typified by: Class III: Manual workers of both genders younger than 30 years, performing fabrication, assembly and repair operations in medium-sized companies in a variety of sectors (garment, metal, wood, rubber, food, etc.), with injuries (inflammation, wounds) to the upper limbs and shoulders, work absences up to two years, and in some cases, relapses. Class VI: Female workers older than 40 years in large organizations in the health sciences and health and social services sectors, with pain or muscular injuries in the trunk or neck, work absences of less than 45 days, and no relapses. The presence or absence of early return to work measures was not a significant determinant of the two last classes (I and IV, cf. Table 3).

4. Discussion The results indicate that fewer than one-quarter of the workers registered in the databases of the four regional offices of the CSST studied between January 1994 and March 1997 were the object of return to work measures. It must be noted, however, that this analysis overestimates the proportion of subjects having benefited from early return to work, since its denominator underestimates the total number of occupational-injury-related work absences. This underestimation is a result of the exclusion from the CSST database of workers absent from work for fewer 45 days and who did not benefit from early return to work measures. Variations in access to return to work measures may be due to the socio-demographic characteristics of workers, the characteristics of their injuries or the structural characteristics of their employers. The following section presents a number of hypotheses—arrived at by comparing the results of our bivariate analyses to those from other studies and by comparing the characteristics of the various typical classes identified in this study—which may explain the observed variations in the presence of return to work measures. The presence of return to work measures is associated with three socio-demographic variables: age, gender and occupational group. The bivariate analyses indicate that workers aged 30—39 years are significantly more likely to be the object of return to work measures. The multivariate analyses, on the other hand, indicate that

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it is workers aged 15—29 years, 40—49 years and older than 50 years who are most likely to be the object of such measures. These results appear to indicate the existence of modulation of the age effect by other factors, for example the characteristics of workers, injuries and employers. Frequent reports of a negative association between age and the probability of returning to work have appeared in the literature (Butler et al., 1995; Johnson and Baldwin, 1993; Strautins and Hall, 1989; Tate, 1992). However, no other study has attempted to determine the relation between age and access to corporate early return to work measures. The proportion of women who were the object of early return to work measures was statistically greater than expected; the inverse relation was observed for men (P< 0.05). Women have been reported to be statistically less likely than men to return to work (Butler et al., 1995; Johnson and Baldwin, 1993), while others have reported the absence of gender-specific effects (Hocking et al., 1993; Raleeh, 1987; Strautins and Hall, 1989). Female gender was a defining variable of Class VI, one of the two typical classes characterized by the presence of return to work measures. This class was also characterized by employment in the health and social services sector and by large companies. In contrast, employment of women was characteristic of two of the three typical classes associated with the absence of return to work measures (Classes V and VII). These two classes were also typified by small to medium-sized service companies. Finally, the only typical class characterized by the employment of men was Class II, in which return to work measures were absent. With the exception of economic sector and employment status, this class is broadly similar to Class VI (characterized by the employment of women and the presence of return to work measures). These results indicate the existence of an indirect association between gender and access to return to work measures, dependent on economic sector and employment status. It is nevertheless clear that these latter two variables are insufficient to explain the observed differences between Classes VI on the one hand and Classes V and VII on the other. These three groups account for a significant proportion of the female service-sector workforce in this study population. The difference between women in Class VI, which is characterized by the presence of return to work measures, and women in Classes V and VII, which are characterized by the absence of such measures, is that in Class VI women are employed in large companies in the health and social services sector. The bivariate analyses revealed that the proportion of non-manual workers who were not the object of return to work measures was greater than expected. These workers were only represented in one class, Class VII, a class also characterized by a predominately female workforce, small or large companies, service-sector activities, and bone injuries to the upper limbs. Cases in the rubber and plastics sector were significantly more likely to be the object of return to work measures, while cases in the transportation and warehousing sector were significantly less likely to be the object of such measures.6 Economic sector was the second best defining factor in the multivariate analyses. 6

A significant negative association (P >0.05) was observed between employment in the transportation and warehouse sector and the presence of return to work measures.

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Company size was a significant determinant of the presence (and absence) of return to work measures. The bivariate analyses indicate that workers in large companies were significantly more likely to have been the object of return to work measures, while workers in small companies were significantly less likely. Three studies have reported similar results (Baril et al., 1994; Drury, 1991; Le´vesque, 1993), while one study of the organizational determinants of resistance to the implementation of return to work policies reported company size to have no effect (Shoemaker, 1989). There are two possible explanations for the observed relation between company size and the presence of return to work measures. On the one hand, Baril et al. (1994) reported that small and medium-sized companies take a more narrowly financial approach to health and safety management, possess no health and safety infrastructure, and depend on CSST rehabilitation services. Large companies, in contrast, were reported to possess more substantial financial resources that allow them to undertake workstation modification. Similar results were reported by Le´vesque (1993), who observed temporary reassignment, one type of return to work measure, more frequently in large companies and in companies in which responsibility for health and safety was assigned to administrative personnel. It is probable that larger companies are able to allocate more human and financial resources to health and safety activities, which increases injured workers’ access to return to work measures. It may also be that greater number of positions in large companies allows them to provide workers with functional limitations greater access to less demanding tasks. A significant positive association was observed between the presence of return to work measures and the following characteristics of injuries: site of injury, nature of injury, duration of work absence (severity of injury) and case status (presence of relapse). The upper limbs and shoulders were the only injury site associated with the presence of return to work measures (i.e. the number of cases in which return to work measures were applied was statistically greater than expected). The bivariate analyses indicate that inflammation was also statistically associated with the presence of return to work measures. Inflammation was also associated with injuries to the upper limbs and shoulders. Inflammation and injuries to these sites were characteristic of only one class also characterized by the presence of return to work measures. Hernia was the only injury exhibiting a negative association (P < 0.05) with the presence of return to work measures. However, the multivariate analyses indicate that hernias were characteristic both of a class characterized by the absence of return to work measures (Class II) and two classes (I and IV) exhibiting no association with either the presence or absence of return to work measures (Baril et al., 2000). The relationship between the nature of the injury and the presence of return to work measures was thus also indirect. Further study of this relationship, taking into account workers’ characteristics and corporate organizational factors, is indicated. The results of the bivariate analyses indicate a significant positive association between work absences of 0–44 days and of 188–365 days on the one hand, and the presence of return to work measures on the other. The relation between work

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absences of 0–44 days and presence of early return to work measures reflects the fact that the CSST database does not include cases of occupational-injury-related work absences of fewer than 45 days in which early return to work measures were not applied. In addition, work absences of 0–44 days were more frequent in large companies, while work absences of 45–90 days were associated with the absence of return to work measures. Furthermore, the two typical classes characterized by the presence of return to work measures exhibited different predominant durations of work absence; while Class III was characterized by absences of 91–183 and 366–730 days, Class VI was characterized by absences of 0–44 days. Overall, the results indicate the existence of two trends. In some cases, companies apply return to work measures from the first day of work absence, while in others, measures are only applied later. This phenomenon is difficult to explain, as the classes in question exhibit many differences in terms of corporate structural characteristics, and the characteristics of workers and injuries. It is noteworthy that in class III, late interventions are characteristic of young workers suffering relapses. This may reflect the awareness by companies in these classes of long work absences and of relapses by their employees, and their application of return to work measures to avoid the long-term disability of younger workers. The presence of relapses was significantly associated with the presence of return to work measures and with work absences of 366–730 days. In this context, return to work measures appear to be a sort of ‘‘last chance’’ before workers lose their right to return to their former position, a period defined by Quebec law as two years. However, it should be noted that the data is inadequate for the establishment of a temporal relation between the time of relapse and the time return to work measures were applied, as these latter could have been applied before or after relapse had occurred. The late application of return to work measures in class III may have another explanation, however. It is possible that the nature of workers’ injuries and occupational group renders it difficult for companies in these sectors to assign workers more rapidly to tasks suited to their functional limitations. The data suggests that workers in this class are primarily manual and suffer primarily inflammation, open wounds and bone injuries that may hinder execution of manual tasks. It may be that companies in this class, which are primarily medium-sized, have few non-manual positions available. The results of our multivariate analyses of the entire study population indicate that five of the seven classes are characterized by the presence or absence of return to work measures. The population profiles generated by the multivariate analyses shed light on the conclusions of the bivariate analyses, and illustrate the complex and interdependent relation between workers’ socio-demographic variables, injury characteristics, and the structural characteristics of the companies on the one hand, and the presence or absence of return to work measures on the other. The bivariate analyses revealed a positive association between the absence of return to work measures and work absences of 45–90 days, as well as a negative association between the presence of return to work measures and employment in the

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transportation and warehousing sector and male gender. The profile of workers in Class II, characterized by the absence of return to work measures, is similar in some respects but different in others: Class II workers are employed in large companies, and should have been, according to the bivariate analyses, the object of return to work measures. Why have large companies in this sector not offered return to work measures? More detailed multivariate analyses of the population of injured workers having benefited from return to work measures revealed a class practically identical to Class II in which return to work measures were absent (Baril et al., 2000). This class is further characterized by: manual work, age greater than 40 years, employment in large companies in the transportation and warehousing sector or the primary sector, and contusions or bone injuries to the lower limbs or at multiple sites. The differences between the classes suggest that the presence or absence of return to work measures may be associated with the nature and site of injury. In fact, many workers with musculoskeletal injuries to the trunk and neck, and, to a lesser extent, the upper limbs, were not offered return to work measures, while workers with contusions or fractures of the lower limbs or at multiple sites were offered such measures. These results suggest that the implementation of return to work measures in the same sector may vary as a function of the nature and site of injuries. Bivariate analyses reveal a positive association between the absence of return to work measures on the one hand, and small company size and non-manual work (itself associated with female gender) on the other. The profiles of Classes V (manual) and VII (non-manual), characterized by the absence of return to work measures, employment in the service sector, absence of relapses, and work absence of up to two years, confirm and complement this conclusion. Here again, detailed multivariate analyses of the population of injured workers having benefited from return to work measures reveal a typical class characterized by: young ( < 30 years) male workers, small companies in the service or retail sectors, bone injuries to the upper limbs, and work absences of three months to two years (Baril et al., 2000). Comparison of this class with Classes V and VII, characterized by a largely female workforce, indicates the existence of gender-specific differences operating within the same sector and across equivalent work absences. In fact, return to work measures were offered to young male, but not female, workers with bone injuries to the upper limbs. The difference in the access to return to work measures by workers in Class V and in a very similar class7 in which return to work measures were available can be explained by differences in the nature and site of injury (contusions to the upper limbs). The results of this research cannot be extrapolated to the entire population of workers having suffered occupational injury, as the cases were drawn from four regional CSST offices, three of which were located in the Montreal region. One effect of this sampling strategy was that certain economic sectors—most notably construction, which has its own administrative unit with the CSST—were underrepresented in the sample. It is also likely that CSST data underestimates the number 7 Female workers in small companies in the service sector (accommodation, restaurant and leisure sectors) with contusions to the upper limbs and relatively long work absences (up to 1 year).

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of cases benefiting from return to work measures, particularly since the application of such measures has become more widespread since 1997, as the results of subsequent case studies suggests. Data collected in 1998 from 16 companies revealed that while 15 of the 16 companies had implemented return to work policies, CSST records indicated that only eight had done so. It was also observed that some companies do not report implementation of such measures to the CSST (Baril et al., 2000). It should be emphasized that the objectives of this study did not include the formation of value judgements about the quality of existing early return to work measures. The CSST database is of limited value for this purpose, and only contains information on the type of early return to work measure each worker benefited from. This information is collected by CSST personnel from workers and employer representatives and never been validated. Ethical considerations dictate that the CSST obtain authorization from the potential study subjects (a random sample of the database’s 13 728 cases), before the researchers contact them. The information supplied by the subjects would then be validated with employer representatives. A study of this type would require resources disproportionate to the objectives of this exploratory study.

5. Conclusion The results reported here indicate that the presence or absence of return to work measures is determined by the characteristics of workers (age, gender, occupational group), the characteristics of injuries (nature, site, duration of work absence, relapses), and the structural characteristics of employers (sector, size). This study was the first to have analysed the interdependent relations between these variables. Furthermore, the results of the multivariate analyses, used to draw up typical classes, complement and shed light on the results obtained from bivariate analyses. In the cases analysed here, the implementation of return to work measures exhibited both intra- and inter-organizational variation, the concrete result of which was differential access to return to work measures. The establishment of typical classes allowed identification of populations with different degrees of access to such measures. These results are useful for both field workers and researchers. Field workers responsible for the rehabilitation of injured workers will find them valuable when attempting to target those workers in most need of attention. Researchers, on the other hand, will appreciate the light the results shed on the characteristics of companies and of workers which must be taken into account when studying the implementation of return to work measures. Thus, while studies of inter-organizational determinants of the implementation of return to work measures must take into account economic sector, corporate size, and the prevalence of various types of injury, studies of intra-organizational variation must take into account the type of injury (nature, site), severity of injury, and workers’ age, gender and occupational category. Further research should be conducted on the potential synergistic and confounding effects of these variables in studies of the relation between the presence of return

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to work measures and permanent return to work. Finally, in light of the lack of information in this field, further research is clearly indicated on the effects of variations in return to work measures on absence from usual work, relapses and the aggravation of injuries, and of the effect of organizational factors on return to work measures.

Acknowledgements The authors would like to thank Thierry PetitJean-Roget and Esther Cloutier for their statistical advice, and the Institut de recherche Robert-Sauve´ en sante´ et en se´curite´ du travail for project funding.

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