Experiences of support to return to work after stroke: longitudinal case studies from RETAKE trial.

Background: Returning to work after stroke has physical, psychological and financial benefits for stroke survivors. However, global evidence estimates return-to-work rates 1 year post stroke at < 50%. Although its importance is acknowledged by policy-makers and healthcare providers, vocational rehabilitation is not always part of National Health Service usual care post stroke. Currently, there is limited evidence of the effectiveness of return-to-work support interventions. RETurn to work After stroKE was a multicentre individually randomised controlled pragmatic trial, with embedded process and health economic evaluations. RETurn to work After stroKE aimed to establish whether Early Stroke Specialist Vocational Rehabilitation plus usual care improves the likelihood of return to work at 12 months post stroke compared to usual care alone. As part of an embedded process evaluation, longitudinal case studies enabled exploration of participants' experiences of support to return to work in the trial.

Objectives: This article aims to understand participants' experiences of being supported to return to work and explores the social and structural factors which support, or act as barriers to, implementation of the Early Stroke Specialist Vocational Rehabilitation intervention.

Method: A longitudinal case-study approach was used to compare experiences of post-stroke return-to-work support received over 12 months by 15 participants who received the Early Stroke Specialist Vocational Rehabilitation intervention plus usual care, and 11 participants who received usual care only. Data were gathered at three time points using follow-up questionnaires, health records, intervention delivery records and semistructured interviews with participants and seven nominated informal carers. Interviews were also conducted with 1 employer and 11 occupational therapists delivering the intervention.

Setting: Sixteen National Health Service sites across England and Wales.

Findings: In the intervention arm, stroke survivors, carers and employers reported benefits from information and support from the treating occupational therapist to facilitate acceptance of, and adaptation to, post-stroke abilities. Participants also valued occupational therapists' provision of sustained and tailored vocational rehabilitation, co-ordinating their care and advocating for them in return-to-work discussions with their employers. Those unable to return to their previous employment were supported to consider alternative options. In contrast, participants who received usual care only reported feeling abandoned when community rehabilitation support ended, typically after 2-8 weeks. Usual care largely focused on restoring physical function, leaving these participants struggling to find return-to-work information, advice and support. Longitudinal case studies enabled psychosocial and environmental factors impacting on participants' return-to-work experiences to be considered.

Limitations: Recruitment to the process evaluation was impacted by the COVID-19 pandemic. It proved difficult to recruit employers for interview, and fewer women participated in the case studies (21 men, 5 women). Direct observation of intervention delivery could not be carried out as planned due to pandemic restrictions on access to clinical areas.

Conclusions: These case studies highlighted self-reported differences between recipients of the Early Stroke Specialist Vocational Rehabilitation intervention plus usual care and participants allocated to usual care only. Aspects perceived as important in underpinning the differences in support included the length of Early Stroke Specialist Vocational Rehabilitation intervention, occupational therapist advocacy, employer liaison and ongoing workplace monitoring. Provision of these core components as part of post-stroke services may support and help to sustain return to work, with associated benefits for stroke survivors and wider society.

Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 15/130/11.