The Practical Application of Theory and Research for PreventingWork Disability: A New Paradigm for OccupationalRehabilitation Services in China?

Katia M. Costa-Black • Andy S. K. Cheng •

Mankui Li • Patrick Loisel

Published online: 2 March 2011

� Springer Science+Business Media, LLC 2011

Abstract Introduction Theoretical frameworks for pre-

venting work disability have evolved over the last decade

and various experimental models have been tested in

occupational rehabilitation settings. The successful appli-

cation and uptake of the most recent research evidence in

rehabilitation practices depend on a complex interplay of

the decisions of multi-stakeholders, including their per-

ceptions of the evidence, a proper regulatory framework for

injury prevention, compensation and disability manage-

ment; as well as the cultural and socioeconomic factors

unique to each country (social context). This paper sum-

marizes the scope of the work disability prevention field

and describes the contextual barriers and support mecha-

nisms for implementing evidence-based practices for dis-

ability prevention in China’s national rehabilitation system.

Methods Expert opinions and relevant publications in the

field were reasoned around key constructs of a translational

model used to identify potential barriers and support plat-

forms for research uptake in China. Results A crucial

component of experimental models for disability preven-

tion is to promote well-coordinated return to work actions

centred in the workplace. Potential barriers and support

mechanisms for implementing this and other evidence-

based recommendations in China are described. Conclu-

sions The complexity of implementing a system-wide

disability prevention model in a country as large and

diverse as China is well-recognized. Improved efforts are

thus required for international knowledge-sharing that can

empower greater research utilization of effective disability

prevention methods in China. The development of well-

connected communities of practice might be a helpful

strategy for enhancing stakeholders’ perceptions, attitudes

and collaborative efforts towards locally relevant and cul-

tural sensitive solutions to work disability.

Keywords Work disability prevention � Musculoskeletal

disorders � Implementation � Translational model

Introduction

In today’s fast-converging global marketplace and with

increased strain placed on governmental social safety nets

due to budgetary cuts and financial pressures, many

countries are seeking more effective approaches towards

sickness absence and work disability related to common

illnesses and injuries [1]. Several European countries have

introduced responsibilities for employers to play a part in

the job retention and rehabilitation process in an effort to

mitigate the human and economic costs of work disability

K. M. Costa-Black (&)

Division of Occupational and Environmental Health, Dalla Lana

School of Public Health, University of Toronto, 155 College

Street, Health Science Building, 5th floor, Room 546-A,

Toronto, ON M5T 3M7, Canada

e-mail: katia.costa.black@utoronto.ca

A. S. K. Cheng

Department of Rehabilitation Sciences, The Hong Kong

Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR,

China

e-mail: andy.cheng@polyu.edu.hk

M. Li

School of Economic Law, Southwest University of Political

Science and Law, Chongqing, China

e-mail: limankui316@yahoo.com.cn

P. Loisel

Division of Occupational and Environmental Health, Dalla Lana

School of Public Health, University of Toronto, Toronto, ON,

Canada

e-mail: patrick.loisel@utoronto.ca

123

J Occup Rehabil (2011) 21:S15–S27

DOI 10.1007/s10926-011-9296-2

[1]. Re-oriented models for contemporary work rehabili-

tation services must include a system-wide effort towards

work disability prevention (WDP) actions that can reduce

unnecessary sick days and promote early and safe return to

work (RTW) or a healthy stay at work (SAW) [2–5]. Such

efforts are particularly needed in developing and newly

industrialized countries where approximately eight out of

ten of the world’s workers reside.

In China, recent reforms to the work injury rehabilita-

tion system demonstrate that initial steps for reducing the

burden of work disability are being taken by government

authorities [6, 7]. These policy-related changes have

spurred an unprecedented debate amongst scholars about

future developments in the work rehabilitation system in

China [7]. In this promising scenario it seems timely to

uncover the practical applications of our current scientific

knowledge with regards to evidence-based recommenda-

tions for disability prevention in a Chinese social context.

At this moment of flourishing public debate in the field of

work rehabilitation China it is also important to create

opportunities for an open and meaningful dialogue between

scientists and knowledge users (i.e. policy makers, insurers,

employers, government agencies, injured workers, health

care professionals and the general public) about WDP

actions and the appropriate roles and responsibilities each

person can play in the process.

The primary aim of this article is to outline potential

barriers to and support for research uptake in WDP by

occupational rehabilitation services in Mainland China

according to key concepts of a translational model. The

secondary aims of this article are: 1) to briefly describe the

scope of WDP; and 2) to provide a short debrief on the

latest scientific evidence in WDP by presenting (on the

theoretical side) a group of well-known conceptual

frameworks on WDP and (on the practical side) a few

operational models of work rehabilitation programs based

on a fully tested combination of clinical and occupational

intervention.

The Scope of Work Disability Prevention and of its

Implementation

Long stretches of disability and inability to work has

devastating psychological, medical, social and economic

effects on workers worldwide [8]. WDP appears as a rel-

atively recent field of research and practice. It has emerged

out of a failure to explain and resolve from a purely clinical

perspective, persistent sickness absence, reoccurrence of

symptoms and the many discrepancies between disease

indicators and SAW or RTW outcomes [2, 3]. Many epi-

demiological and review studies coming from multiple

perspectives (e.g. public policy, sociological, clinical and

economical) have demonstrated that work disability is

often the result of complex interplays involving several

stakeholders (e.g. insurers, lawyers, employers and health

care providers) who may interact positively or negatively

with the worker during the disability process [3, 5, 8]. It

can also arise depending on how the health, compensation

and workplace systems manage or regulate sickness

absence and work injuries. For instance, an inadequate

compensation policy may disincentive employers to invest

in work accommodations and to support RTW after injury

or illness. The lack of work accommodation options or

workplace support can delay or impede the worker to

return to his function [5]. Moreover, a number of recent

studies have shown that the RTW experience of a worker

can be negative and unsustainable depending on the type of

medical care and information received by providers in all

phases of recovery [9, 10]. In fact, many clinical inter-

ventions for musculoskeletal disorders and the on-going

diagnostic search in cases involving non-specific anatomic

or pathophysiologic causes of pain (e.g. non specific back

pain) have been proven to be associated with poor RTW or

SAW outcomes [11, 12].

To overcome the above-mentioned challenges—which

are often outside the scope of clinical resolution alone—a

great deal of research has recently been devoted to the

testing and designing of a combination of clinical and

occupational interventions that show positive RTW/SAW

outcomes [11–13]. An example of these interventions is the

Sherbrooke model, developed in Quebec (Canada), a well-

known model for preventing disability related to back pain

[14]. Although this and other evidence-based interventions

for WDP seem promising, implementation of practical

solutions at the public health level remains a great challenge

in many parts of the world [3]. In China, the national Work

Injury Rehabilitation expert advisory committee proposed

two new national standards on medical, occupational and

social rehabilitation which were approved by the Ministry

of Labour and Social Security in 2008 [15]. The first stan-

dard is the Provisional Standards on Diagnosis and Treat-

ment for Work Injury Rehabilitation, which specifies the

eligibility standard for in-hospital rehabilitation, duration

for in-hospital rehabilitation, evaluation standards for

vocational and social rehabilitation, standards for termina-

tion of rehabilitation, etc. The second standard is the Pro-

visional Standards on Service Items for Work Injury

Rehabilitation, which specifies the service items for reha-

bilitation: it includes functional evaluation, treatment,

counselling and training programs needed for rehabilitation.

These two national standards are new attempts to incorpo-

rate the latest developments in the field of work rehabili-

tation and might pave the way for closer collaboration

among work injury insurance agencies, injured workers,

rehabilitation agencies, and other key stakeholders. These

S16 J Occup Rehabil (2011) 21:S15–S27

123

government-approved collaborations (which are still at an

early stage of development) might represent practical

opportunities to bypass old outdated paradigms with mod-

ern, evidence-based models which promote the collective

buy-in of different groups of stakeholders [16].

Relevants Conceptual Frameworks in WDP

Recently, several conceptual models of work disability and

RTW have been reviewed and described in various papers

[17–19]. Table 1 shows five of these models and presents

their key features (i.e. their short descriptions, their key

components and their graphic representations). Each model

provides a different and yet comprehensive picture of

disability, showing at a glance the dominant contemporary

conceptualization of WDP. The first model describes work

disability issuing from back pain and it was initially pub-

lished by Waddell in 1987 [20]. It was derived from the

Engels’ biopsychosocial model, adding to back pain the

dimensions of attitudes and beliefs, psychological distress

and illness behaviour, surrounded by the social environ-

ment [20]. However, the workplace system—a crucial issue

to consider when dealing with work integration—was not

specifically named. Another well-known disability model

is the International Classification of Functioning (ICF)

issued by the World Health Organization (WHO) in 2001.

This model classifies participation and it includes con-

structs related to the environment at large, but again

without clarifying the role of work or the workplace system

in the disability and RTW process [18, 21]. The first con-

ceptual framework mentioning work demands (biome-

chanical and psychological demands) and relating them

with behavioural responses was the Feuerstein’s model for

work re-entry of persons presenting with musculoskeletal

problems (upper extremity), published in 1991 [2]; the first

one mentioning the workplace system and many of its

macro and micro components was the Institute of Medicine

(IOM) model (2001) [22]. Both of these conceptual

frameworks have boxes and arrows showing the complex

linkages existing among the worker’s biological and psy-

chological states, the workload and occupational disability.

They posit the idea that the workplace, and not only the

worker, is part of the disability problem. Another way to

conceptualize the work disability problem was developed

by focusing on the main stakeholders—workers, employ-

ers, compensation insurers and healthcare providers—

viewed as actors representing multilevel systems which

may contribute to create the disability as well as resolving

it [19]. A further version of this framework has placed

these systems in the larger political and cultural context

showing the societal influence on the work disability pro-

cess [3]. The diagram avoids linear relationship arrows,

choosing instead to simulate a scenario where the players

interact and might have to follow different rules depending

on their perspectives and objectives. Often in this scenario

conflicts between players may directly impact the RTW

process. This framework has been cited as an ecological/

case management model of work disability [17].

In summary, today’s conceptual frameworks used to

explain work disability and to guide related-preventive

actions—such as the ones showed on Table 1—appear to

be complementary to one another in their constructs and

main principles. Further work is needed to reconcile them

in a uniform and even more comprehensive manner, pos-

sibly integrating a transdisciplinary view of prevention,

compensation and rehabilitation.

Evidence-Based WDP Strategies Based

on the Sherbrooke Model

When it comes to restoring a person’s capacity for work

after an injury in a sustainable and effective manner,

clinical interventions alone have proven to have limited

effect and even the opposite effect of delaying RTW when

applied too early [23]. Early clinical interventions (e.g. first

four weeks of absence from work for back pain) may

deliver unnecessary care to those healing quickly and

without risk for prolonged disability. Furthermore, pure

clinical interventions do not take into account factors

present in systems other than the health care system, such

as the workplace and insurance/compensation systems.

Research evidence shows that timely and effective coor-

dination of actions (within and outside the workplace)—as

well as closer attention to RTW/SAW determinants that

can hinder or promote work disability—are effective in

reversing the work disability process [5, 24]. As shown on

Table 1, many disability and RTW models contemplate

social and workplace components beyond those measured

in clinical settings and attention to those components are

essential for an effective and integrated ecological case

management approach.

Implementing such a complex case management

approach as part of occupational rehabilitation services

requires undertaking a shift from the usual biomedical

paradigm centred on the disease to a WDP paradigm cen-

tred on multi-level decisions and determinants of RTW and

SAW [17, 19]. A recent review of the literature shows that

several occupational rehabilitation services around the

world are beginning to adopt such multi-systems approach

in which stakeholders’ actions and their support are inte-

grated in the rehabilitation plan [25]. These contemporary

work rehabilitation programs promote cost-effective

actions that can result in better recognition of workers’

ability to RTW while avoiding the over-medicalization of

J Occup Rehabil (2011) 21:S15–S27 S17

123

Ta

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S18 J Occup Rehabil (2011) 21:S15–S27

123

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J Occup Rehabil (2011) 21:S15–S27 S19

123

the problem and removing system’s related barriers to

RTW [12, 13, 26–29].

An example of such operational model is the Sherbrooke

model developed and implemented first in an occupational

rehabilitation setting in Quebec (Canada) for low back pain

cases [14]. The evidence-based principles of the Sherbrooke

model are as follows: 1) it uses an inter-organizational and

case management approach for dealing with back pain cases;

2) early reassurance and advice about pain and activity; and

3) a combination of occupational and clinical rehabilitation

interventions applied to promote activity resumption and

graded RTW (including improvements or changes in the

workplace setting). This operational model has been fully

tested in Canada and in the Netherlands [14, 26–29]. In the

province of Quebec (Canada) it has been applied to workers

of 31 workplaces, all of whom were absent from work at the

sub-acute stage of work-related back pain [14]. When

evaluated with a randomized controlled trial it was corre-

lated with increased RTW outcomes by 2.4 times compared

to the usual clinical care interventions [14]. Moreover, after

a six year follow-up the intervention was shown to be very

cost-effective in terms of financial savings (5$ returned for

1$ invested in innovative interventions) and in terms of

working days saved from disability [26]. The Sherbrooke

model has been contextually adapted in the Netherlands

using the same operational principles in two randomized

controlled trials; one in a population of workers with sub-

acute back pain and another one in a population of workers

having chronic back pain [28, 29]. In these two trials,

intervention effectiveness was similar to the levels demon-

strated in the Sherbrooke randomization [14].

The above-mentioned principles of RTW interven-

tions—i.e. the ones proposed by the Sherbrooke model—

are now largely acknowledged as evidence-based princi-

ples utilized in occupational rehabilitation for reducing

work disability and for promoting early RTW [11, 25].

Other locations besides the Canadian and the Dutch trials

have experimented or are initiating implementation of this

intervention model [13, 30, 31].

Three of these innovative strategies are described here

(Table 2) to serve as case examples of locally adapted

models in the field WDP. The three programs implemented

by occupational rehabilitation services in Canada, Den-

mark and Brazil have in common the fact that they have

been developed according to key principles of a well-tested

operational model: the Sherbrooke model [14]. They rep-

resent public health initiatives already tested or under

development (in pilot testing stage) with the common aim

of promoting well-coordinated actions between stakehold-

ers and government agencies for reducing prolonged work

disability. Because of their different jurisdictional and

cultural contexts they may vary in terms of time they take

to initiate rehabilitation, the professionals involved in the

interdisciplinary teams, the required inter-agencies agree-

ments, how stakeholders’ actions are monitored, etc.

Despite their different jurisdiction regulations, each

example presented in Table 2 provides logistical opportu-

nities for further discussion of research dissemination and

adaptation in other needed contexts.

As it has been proposed by the Sherbrooke model and

other successful WDP strategies, these three programs have

adopted the following evidence-informed recommenda-

tions: (1) to centralize the rehabilitation plan in the work-

place rather than in a clinical setting; (2) to use

interdisciplinary teams and an inter-organizational approach

to reintegrate workers back to the workplace as early as

possible; and (3) to shift the rehabilitation plan from a pure

disease/injury focus to a well-coordinated ecological case

management model with attention to interactions between

all pertinent systems (i.e. the personal system, the workplace

system, the compensation/insurance system and health care

system). This type of complex intervention is very difficult

to develop and evaluate, but can be successfully imple-

mented when researchers, knowledge users and implemen-

tation agents work together on a local work rehabilitation

model, adapting core evidence to their contextual needs [30].

However, this has rarely happened worldwide and in most

countries, including those where effective interventions

have been tested, work disabled persons are still deprived of

best evidence-based management of their case [1].

Using Key Concepts of a Translational Model

for Discussing Research Uptake

One of the main difficulties in implementing evidence-

based WDP innovation is the common misconceptions

among stakeholders about RTW interventions and which

role each player has in implementing them [5, 24]. Franche

et al. [5] recommend that specific research methods should

be developed for engaging stakeholders so that they would

have a better understanding of each other’s respective

actions, decisions and interests in the context of RTW or

the SAW processes. Loisel et al. [3] also recommended that

researchers more clearly elaborate the conceptualization of

the broader context where stakeholders’ inter-relationships

take place.

Many translational models suggest that it is essential to

synthesize the local context where the evidence could be

implemented before drawing conclusions on the potential

adoption mechanisms and actions/responsibilities required

for effective implementation. As such, we have identified

from the knowledge transfer literature a translational model

called the Ottawa Model of Research Use (OMRU) to help

us build a case on how WDP research evidence could be

potentially translated into China’s current occupational

S20 J Occup Rehabil (2011) 21:S15–S27

123

rehabilitation system [32]. This model seems particularly

relevant in developing countries where many barriers to the

application of knowledge might exist and little evaluation

has been conducted. China is only taken as an example to

illustrate how the elements of the context have to be taken

into account and how efforts already made locally may

serve as basis for research uptake.

As shown in Fig. 1, the OMRU [32] consists of three main

columns representing the process of assessing, monitoring,

and evaluating many elements that are important in the

decision to implement an innovation. Given the early stages

of research and scientific discussions on implementing WDP

innovation in China, this paper only focuses on the concepts

that are important for the baseline assessment of the uptake

of the innovation, i.e. the concepts presented in the first

column of Fig. 1, ‘assessing barriers and supports’. These

concepts are: (1) the ‘evidence-based innovation’ (already

described with examples in Table 2); (2) the ‘potential

adopters’ (i.e. practitioners, policy makers, patients and

other stakeholders involved in the research uptake and their

degree of readiness for evidence implementation); and (3)

the ‘practice environment’ and the many contextual barriers

and supports for research use and implementation.

According to the OMRU, only when the barriers related to

the practice environment or related to potential adopters of

the innovation have been addressed can the local strategies

for dissemination of the new practice be developed [32].

Barriers to and Supports for Implementing Evidence-

Based WDP Actions in China

The ‘Potential Adopters’ of the Innovation

With the enactment of the Trial Measures for Employees’

Work Injury Insurance (No. 266) in 1996, government

Table 2 Examples of three WDP innovations based on the Sherbrooke model

Name of the initiative Country Innovation attributes Main results thus far

PREVICAP program

(Quebec) [14, 19]

Canada Developed directly from the experience with the

Sherbrooke model for back pain, it contains two

main steps: the Work Disability Diagnosis and

the Therapeutic RTW

Implementation in 4 different regions within

Quebec has been suspended due to a policy-

related disagreement between public

stakeholders. One unit in Longueil remained

active and showed that after a 1 and 3 year

follow-ups only 24% of workers off work for an

average of 10 months were not working due to

musculoskeletal disorders

The Therapeutic RTW is centralized in the

workplace and it is a graded process where the

worker progressively returns to regular work

It is an evidence-based program that addresses

worker’s health perception and self-efficacy

It promotes concerted action between stakeholders

from the worker’s first day enrolment in the

program (inter-organizational approach)

Coordinated and tailored

work rehabilitation

(CTWR) [13]

Denmark It contains a screening phase for identification of

barriers to RTW and work disability indicators

(based on the ICF and the bio-psychosocial

model)

It has demonstrated $ cost-saved at 6 months and

$$ cost-saved at 12 months

It has resulted in fewer sickness absence hours

It proposes an action-oriented rehabilitation plan

based on agreement between the rehabilitation

team and other stakeholders (continuous

feedback)

It is offered to workers after 4–12 weeks of sick

leave due to musculoskeletal disorders

CESAT–Salvador (Bahia)

RTW program [31]

Brazil It contains a screening phase for identification of

barriers to RTW and work disability indicators

(based on the ICF, the bio-psychosocial model,

and the WoDDI—an evidence-based instrument

developed by the PREVICAP program team)

This program is initiating its pilot phase of

implementation and no randomization studies

have been completed to date. A multiple case

study is being carried out at this stage to identify

preliminary implementation barriers

It proposes a multi-agency plan of action for

effective RTW, involving mainly labour unions,

the local social welfare agency, the local worker’s

reference and rehabilitation center, and the local

public healthcare network (which involves all

healthcare providers related to the disability case)

It establishes formal agreements with employers

for minimizing a potential job loss or instability

during the RTW and rehabilitation processes

J Occup Rehabil (2011) 21:S15–S27 S21

123

agencies in China have assumed responsibility to provide

compensation and medical services to those who were

injured at work [6]. However, the conceptualization of

work rehabilitation and integration was not really devel-

oped until January 1, 2004 when the Regulations on Work

Injury Insurance was formally promulgated across the

whole country with emphasis on prevention, rehabilitation

and compensation of work injury [33]. According to

incomplete statistics issued in 2007, the total number of

workers who became work disabled due to work injury in

China has reached more than 1 million [33], which remains

a modest figure when compared to China’s total population

of around 1.3 billion inhabitants. However, in order to

prevent a growth of this number in parallel with the

growing level of industrialization in the country, potential

adopters of the WDP innovation in China may want to

include the usual stakeholders—policymakers, healthcare

providers, injured workers, and employers—in their new

policy developments. As elsewhere in the world, the

challenge will be to rally them to OMRU key concepts with

the common goal of implementing WDP innovation, while

considering their awareness/attitude and knowledge/skills

in the context of current practices.

Awareness/Attitude

Generally speaking, the overriding concern of most enter-

prises worldwide remains the economic growth and

viability of their businesses and they may pay little atten-

tion to sickness and work disability issues and how they

can impact workforce health and well-being, as well as

work productivity and efficiency [1]. In China, once

employers have paid the premium for Work Injury Insur-

ance, they may believe that their responsibility has fin-

ished. As in other countries, Chinese employers may not be

aware that they have a stake in ensuring early and sustained

work resumption and can gain significantly from their

workers’ timely return to productivity [24, 34]. On the

other hand, the most important concern of the current

injured worker remains securing compensation for his/her

work injury instead of rehabilitation [34, 35]. When injured

workers are asked to make a choice between low com-

pensation with rehabilitation and RTW and high compen-

sation without rehabilitation or RTW, many injured

workers choose the latter [35]. This attitude, likely

responding to the structures and incentives of the current

system, may inhibit the coordination of actions between

employers, insurance fund agencies, healthcare/rehabilita-

tion agencies and injured workers. Lacking an appropriate

case management system, injured workers may continue to

focus on compensation benefits [15] while employers

worry about the unpredictable burden of the rehabilitation

services and fear a disruption of the production process

[33]. Moreover, healthcare agencies and rehabilitation

centres are independent market players in China, including

those contracted by the Work Injury Insurance fund. These

Fig. 1 The Ottawa Model of

Research Use (OMRU) and

highlighted components

discussed in this paper (adapted

from Graham and Logan [32])

S22 J Occup Rehabil (2011) 21:S15–S27

123

stakeholders’ competing interests and their attitudes, as

well as the lack of specific government regulation when

workers are transitioning from medical care to rehabilita-

tion, may compromise implementation of evidence-based

WDP strategies in China.

As it has been observed and successfully applied in

other complex fields of practice, well-connected commu-

nities of practice may offer potential solutions for inte-

grating research evidence into practice and for improving

current practice standards [36]. The experiences of several

communities of practice in public health show that stake-

holders often lack awareness of evidence-based practices

and these communities can provide a participatory envi-

ronment for stakeholders to learn, share expertise, build

trust in one another and develop common understanding on

which interventions are worthy investing their time and

efforts [37]. In China and elsewhere they could be devel-

oped, for instance, with the aim to foster (at the local level)

stakeholders’ common understanding and positive attitudes

towards disease and illness, as well as to build cooperative

interactions for early and sustainable RTW.

Knowledge/Skill

In 2002, a territory-wide survey counted about 2,000

medical rehabilitation facilities in Mainland China, 442 of

them located in general hospitals of major cities and gov-

erned under the Ministry of Health, while the remaining

group were supervised by the Ministry of Civil Affairs and

the Federation of Disabled Persons of China [38]. In 2001

the Guangdong Provincial Work Injury Rehabilitation

Centre was established as the first of its kind in the country

directly funded by Department of Labour and Social

Security [6]. It has taken up the responsibility to spearhead

the development of a service model in rehabilitation for the

rest of the provinces in the country. In addition, it has also

served as the national research centre for assessment and

RTW interventions for injured workers [6]. In 2007, the

Secretary of Work Injury Insurance Department of Minis-

try of Labour and Social Security of China made the fol-

lowing recommendations: (1) to establish the speciality of

occupational rehabilitation in universities and research

institutes; (2) to conduct training and continuous education

with the support of the rehabilitation institutes at home and

abroad; and (3) to guarantee the provision of professionals

who can offer quality care for the rehabilitation of multiple

work injuries and disabilities [33]. This effort is indicative

of recent developments to improve the educational cur-

riculum of rehabilitation professionals able to apply recent

best practices in WDP at the community level.

As illustrated in Table 2, in very different parts of the

world occupational rehabilitation services are placing

greater focus on understanding and dealing with the

workplace and compensation systems in order to transition

from the traditional biomedical model to a biopsychosocial

perspective. These changes also reflect changes on reha-

bilitation professionals’ curriculum. The three RTW pro-

grams showed on Table 2 follow an ecological case

management model with emphasis on delivering occupa-

tional and clinical interventions to prevent long-term dis-

ability. In these programs rehabilitation professionals (or

the rehabilitation team leader) must engage with various

stakeholders in an open exchange about which are the

feasible RTW strategies and sustainable solutions to the

problem. As China embraces social and medical rehabili-

tation while building its work injury rehabilitation model, it

is important that opportunities for such a multi-system

exchange are created and incentivized by new policies and

the society as a whole. Rehabilitation professionals in

China must be aware of (and ready for) such opportunities

and this should reflect on the development of a more

competence-based curriculum in disability prevention and

management.

Current Practices

Today it is largely acknowledged that disability prevention

and applied RTW/SAW interventions must be imple-

mented at the clinical, administrative and social levels in a

coherent and coordinated way [3]. However, a large sci-

entific debate currently exists on how in any country one

can successfully implement such multi-level actions. The

experience of implementing a multi-stakeholder RTW

programme in Sweden showed that it requires on-going

effort, time and reflection from the part of the various

stakeholders [39]. In Quebec (Canada), the PREVICAP

program (Table 2) showed very positive results in terms of

cost savings and reduced disability duration; however, the

program faced major implementation barriers due to dis-

agreement between public stakeholders. A useful approach

to successfully implement such a complex intervention is

to not only take into account local stakeholders’ behaviours

but also to identify the elements relevant to decision-

making, such as benefits, disadvantages and costs. In China

this issue is under debate at this moment. Li [33] recently

proposed seven key points for better decision-making on

building China’s model for occupational rehabilitation

practices: (1) to elaborate and test a context sensitive

model; (2) to improve current policies about work reha-

bilitation; (3) to establish a system of standards for reha-

bilitation practices; (4) to improve the administrative

system related to social benefits and social responsibilities;

(5) to develop an effective service delivery system; (6) to

strength the educational training of rehabilitation profes-

sionals; and (7) to conduct a scientific study with interna-

tional cooperation on the rehabilitation practices in China.

J Occup Rehabil (2011) 21:S15–S27 S23

123

At the core of this debate is the discussion about how to

build best practices in work rehabilitation in China and to

develop support mechanisms for better engaging stake-

holders in RTW and rehabilitation actions.

The ‘Practice Environment’ Where the Innovation

Could be Implemented

The practice environment directly influences the success of

research use: it has both enabling and constraining effects

on performance [40]. According to the current develop-

ment of occupational rehabilitation services in different

provinces in China, the most usual practice environment is

in large and middle-sized cities or regions where there are a

large number of workplaces participating in and contrib-

uting to the Work Injury Insurance fund. As an example, in

the Guangdong province (the number one exporter

nationwide for 18 consecutive years according to the

Department of Foreign Trade and Economic Cooperation

of Guangdong Province in 2004), the Work Injury Insur-

ance agency was able to set up its own specialized work

injury rehabilitation centre and to manage it directly under

the Department of Labour and Social Security [41]. A

recent study has indicated that when this centre manages to

integrate the actions of several key stakeholders, the usual

social and workplace barriers encountered in the arena of

RTW are removed [33]. This model might become a

standardized system for nationwide occupational rehabili-

tation services if continues to be shown effective in

reducing sickness and work disability rates [33].

Cultural Environment

Although China has 5,000 years of progressive and illus-

trious history it has not developed a widely established

notion of social security. After 1949 communist China

brought social security benefits; however, they were phased

out by the introduction of a market economy after 1980.

This transition has induced people in China to save more

money in order to pay for access to these previously

‘‘public’’ services. As previously mentioned, many Chinese

people prefer higher prolonged compensation instead of

rehabilitation that might be able to return them to improved

work capacity [35]. This cultural barrier may hamper the

development plan of a work rehabilitation model in China

and compromises cooperation between injured workers,

insurance funds and rehabilitation agencies that have the

mandate to prevent and manage work disability. A large

awareness-raising effort on behalf of various stakeholders

and the general public leading to prevention awareness and

coordinated management of work disability might improve

this situation. A sustained general population educational

media campaign such as the one that had experimental

success in Australia might be an effective solution if

adapted to the local situation [42].

Structural Environment

Currently, there are more than 200 million migrant workers

from rural areas who work in large industrial settings

located in urban areas [43]. Once injured in the workplace

these workers receive workers’ compensation and many of

them return to rural areas in order to avoid extra living

expenses. In doing so they are deprived of access to

rehabilitation facilities which are lacking in rural areas. In

2006 the total income of the Work Injury Insurance fund in

Shenzhen City was ¥764 million (the official currency of

the People’s Republic of China, Renminbi, is represented

by the symbol ¥) among which ¥102 million was allocated

for rehabilitation expenses [44]. However, the actual

expense incurred by rehabilitation was only ¥8000, as most

of the injured workers had returned to their rural area after

they had claimed compensation [44]. Again, diffusion of

appropriate education and policy development might

improve a situation due in part to the accelerated speed of

development of China.

Economic (and Social) Environment

Although at this moment in China ‘‘work injury rehabili-

tation faces an unprecedented opportunity for develop-

ment’’ [33], close attention should be paid to a number of

unique socio-economic challenges particular to such large

and newly industrialising economy. As it has been pointed

out in recent studies, the massive economic disparity

between more industrialized cities and rural areas makes it

very difficult to implement rehabilitation schemes that

would work across all parts of the country [7, 33, 35].

Moreover, financial incentives play a major role in the

determination of implementation priorities in disability

prevention, and in China (at least up until now) the sup-

ports and incentives for employers to accommodate

workers early in the RTW process appear weak [34].

Regardless of the current lack of incentives, early RTW

recommendations should only be applied when workplace

interventions are feasible and can be monitored closely [5].

Related to this issue is China’s level of development of

social protection and rights [33]. To cite Lee [45] ‘‘At this

stage of China’s development, the first imperative in the

protection of its citizens’ human rights is its duty to provide

a basic standard of living.’’ Only after China meets the

basic medical and occupational health needs of the general

public will it consider implementing advanced rehabilita-

tion schemes. Thus it will remain a challenging to imple-

ment WDP innovations (as the examples showed on

Table 2) without assuring that the workplace is a safe place

S24 J Occup Rehabil (2011) 21:S15–S27

123

to be for workers who are injured or not. The rehabilitation

program that is being developed in Bahia (Brazil) proposes

an operational model whereby workplace surveillance

actions are integrated into an ecological case management

approach as proposed by the Sherbrooke model [31].

Although this is a good example of a work rehabilitation

model built from research evidence and social debate, more

research is required to better understand the variability of

outcomes and theoretical foundation particular to WDP

strategies developed for emerging economies like Brazil

(and China).

Unexpected Event

The 2008 financial crisis severely affected economic

growth in Europe and North America and caused a global

recession. Many factories in China’s southeast coastal

provinces had to be closed or have even gone bankrupt due

to lack of orders. As a result, it is estimated that more than

20 million migrant workers lost their jobs and returned to

the rural areas where they originally lived [46]. As the

global economic crisis abated, those closed factories have

been reopened and are now operating at full capacity in

order to cope with the increasing orders. It is estimated that

there is now a shortage of 6 million workers in manufac-

turing industries in China. In order to address this ‘‘short-

age of labour’’ many manufacturing enterprises are

improving wages and working conditions. They have also

encouraged injured workers to receive rehabilitation ser-

vices in order to avoid a further loss of existing human

resources [43].

The Legal/Regulatory Environment

Beyond the components of the ‘practice environment’

described in the OMRU, several legal/regulatory barriers

and support mechanisms for WDP research uptake in China

were identified.

A universal workers’ compensation system applies to all

provinces in Mainland China for prevention, compensation

and rehabilitation, yet compensation has been the primary

focus of Work Injury Insurance to date [43]. Musculo-

skeletal disorders, which can result in long-term work

incapacity, have not yet been recognized as a compensable

occupational health problem in China. These disorders are

not even on the list of eligible diseases for an assessment

by a medical institution certified by the provincial health

department. Recently implemented policies are aiming to

facilitate the access to work rehabilitation services for

workers with any injury or illness that disrupts work

activities [7].

A recent study shows that no clear administrative

mechanism has yet been established nationwide to

disseminate and implement the provisions of the new Work

Injury Insurance regulations regarding rehabilitation [34].

However, different models of service delivery have been

explored thus far by the Work Injury Insurance agency of

the Department of Labour and Social Security that may

improve the current situation [16, 33]. The different models

proposed are: 1) rehabilitation institutions directly estab-

lished by labour departments (Work Injury Insurance

fund); 2) rehabilitation agencies operated by medical

institutions in cooperation with labour departments; and 3)

third parties rehabilitation services purchased from private

medical institutions [15]. Regionally there have been major

differences on the choice of these models impacting the

standard of care delivery across the country [7].

Two main opportunities for WDP research uptake in

China were identified. The first opportunity relates to

recently introduced public policies which are in favour of

new occupational rehabilitation practices. In 2007, the

Ministry of Labour and Social Security released the

Guidelines on Enhancing the Piloting Work of Work Injury

Rehabilitation which explicitly stipulates the relationship

between medical rehabilitation, occupational rehabilitation

and social rehabilitation [7]. This act is an important first

step in the development of a comprehensive and tailored

rehabilitation practice for injured workers in China. Two

national standards were also released which provide

detailed guidance on the evaluation of functional ability

and rehabilitation services for medical, social and occu-

pational rehabilitation. These two national standards apply

to more than fifty percent of the population affected with

work disability in China [44]. These policy procedures will

likely facilitate improved coordination of actions among

government agencies, insurance funds, medical institutions

and rehabilitation institutions, and provide support for

newly implemented occupational rehabilitation practices

nationwide. Such measures are consistent with recent evi-

dence and best practice models of WDP that underline the

importance of bringing different stakeholders on board and

coordinating their actions (as illustrated in Table 2) [3].

The second support for research uptake concerns the

new regulations on early RTW and job security. Under the

Regulations on Work Injury Insurance, the government

pays employers directly for compensation related to loss of

earnings and in return the employer must guarantee

employment status [33]. Moreover, employers are required

to provide injured workers’ wages during the medical care

(or rehabilitation) period and to make provisions regarding

‘‘obligation of re-employment’’. This new regulation, if

effectively implemented, can be seen as a legal safeguard

for injured workers’ early and more sustainable RTW after

rehabilitation and hopefully can facilitate the RTW coor-

dination of actions between workers, rehabilitation pro-

viders and employers. During the implementation process

J Occup Rehabil (2011) 21:S15–S27 S25

123

of these new policy regulations it is necessary to develop

multiple ongoing strategies for monitoring and evaluating

their outcomes in relation to the worker, practitioner and

system as suggested by the OMRU (Fig. 1).

Conclusion

Work disability involves multiple factors and there are now

a number of well-recognized disability prevention strate-

gies offered as part of comprehensive occupational reha-

bilitation services that have been successfully piloted in

different countries. These strategies mainly target specific

biopsychosocial and environmental/workplace factors in an

attempt to facilitate the RTW and SAW processes. How-

ever, such models require a contextual adaptation in order

to be successfully implemented in a given country. They

also require joint agreements, good cooperation among

stakeholders and a common understanding of the conse-

quences of work disability.

As a top emerging economy, China will likely improve

its services for injured workers and in doing so it has the

opportunity of drawing on positive experiences from other

countries and adopting best practices from recent research

advances in WDP. The development of a WDP system

should be based on a balance between adopting best inter-

national practices in such a way that is sensitive to China’s

culture, history and needs, while taking care to avoid and

learn from the implementation pitfalls that other countries

may have encountered in the past when building their work

rehabilitation system model. Similar approaches might also

be applied to the specific situations of other developing

countries in the East and Southeast Asian regions.

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