Ref-009

John Frank, M.D., M.Sc., investigator. Dr. Frank is a family physician and an epidemiologist. While managing the project, Dr. Frank was an adjunct professor at UC Berkeley's School of Public Health and a professor of public health sciences at the University of Toronto. In addition, he co-founded the Institute for Work & Health in Toronto, Canada.

Juliann Sum, J.D., M.S., investigator and project coordinator. Ms. Sum is an attorney and an industrial hygienist. Since 1994, Ms. Sum has coordinated Commission-sponsored research and educational projects based at the Institute of Industrial Relations and the Labor Occupational Health Program, UC Berkeley. In previous positions, Ms. Sum worked for a labor union to create and administer an occupational health program and represented insurers in complex insurance coverage litigation.

Julia Faucett, R.N., Ph.D., F.A.A.N., project consultant. Dr. Faucett is a nurse and an associate professor, and the director of the Occupational and Environmental Health Nursing Program at the School of Nursing, UC San Francisco.

Laura Stock, M.P.H., project consultant. Ms. Stock is a health educator and an associate director of the Labor Occupational Health Program, UC Berkeley's School of Public Health. C. Planning Activities Prior to the start of this project, the project team helped plan and conduct a meeting with the Commission's Construction Industry Task Force on February 16, 2000. At this meeting, representatives from labor and management discussed return-to-work problems and issues that are of particular concern in the construction industry in California. The participants then brainstormed on potential solutions. During the meeting, ideas were organized into the following categories: (1) informational and educational solutions, (2) cultural and attitudinal solutions, and (3) economic and legal solutions. An advisory committee was formed to enable the project team to obtain advisory input from organizations and persons with practical experience in workers' compensation and return- to-work issues. To form this committee, the team assisted the Commission in selecting and inviting members of the workers' compensation community. The first meeting of the advisory committee was held on March 31, 2000. Twenty-three persons attended, including representatives from the claims industry, employers, labor, community legal services, applicants' attorneys, injured workers, the Department of Industrial Relations, the Division of Workers' Compensation, and the Industrial Medical Council. At this meeting, the participants reviewed the overall scope and activities of the project. They also reviewed the ideas discussed by the Construction Industry Task Force and further discussed and elaborated on problems and solutions that might be applicable in a broad range of industries. Finally, the participants were invited to advise on methods to recruit participants for the focus group sessions. Ideas generated in the meetings of the Construction Industry Task Force and the Project Advisory Committee were used in the data collection, as described in the next section of this report. III. RESEARCH ACTIVITIES A. Qualitative Research Methodology...............................................................................................6 B. Recruitment and Enrollment..........................................................................................................8

Health Care Providers.................................................................................................................9 C. Invitation and Informed Consent.................................................................................................10 D. Design of the Discussion Guides................................................................................................11 E. Facilitation and Observation of the Sessions............................................................................11 F. Transcription and Analysis..........................................................................................................12 This project was designed as an exploratory study, to obtain preliminary information on important issues and concerns regarding injured workers' prospects for future, long-term employment, as viewed by some of the main participants in the California workers' compensation system. The project team convened five focus groups of study participants. The participants were grouped with other persons who had similar roles in the workers' compensation system to encourage freer expression of opinions and ideas. Each group discussed their experiences, perspectives, insights, and opinions regarding different efforts both successful and unsuccessful for returning injured workers to sustained employment. They also discussed major barriers they have observed in trying to return, or trying to help injured workers return, to sustained employment. Finally, they discussed possible solutions to overcome those barriers. A. Qualitative Research Methodology This study used focus groups to obtain data on experiences, insights, and barriers to long- term, sustained employment for injured workers. Focus group research is used to collect in-depth qualitative data that closely reflect the perceptions, feelings, and manner of thinking of the participants. This contrasts with written questionnaires that often seek limited answers to closed- ended questions to generate data that can be analyzed quantitatively. Focus group data are subjected to rigorous review and analysis following specific guidelines and accepted research 7 procedures. Focus groups are an important research method used in applied social research, especially in the health field. Researchers have used focus groups, for example, to learn about attitudes, beliefs, and practices related to birth control use in economically developing countries, declines in fertility following modernization, parents' educational preferences for young boys and young 8 girls, and support of aging parents by adult children. Public agencies and nonprofit 9 organizations have used focus groups to increase the effectiveness of their programs. In California, for example, a focus group study was recently conducted to understand parents' views toward state programs that offer health coverage for children in low- and moderate-income 10 families. In a focus group, the interactions in the group increase the participants' candor, probe the thinking behind participants' opinions, and uncover concerns below the surface that were not apparent to researchers beforehand. In other words, focus groups generate data that would be much less accessible without the interaction of the group. Therefore, rather than merely providing data on whether a person is satisfied with a particular program, focus groups also provide specific information on why the person is satisfied or dissatisfied and how the program could be improved. The moderator of a focus group facilitates interaction between the participants by presenting questions in a neutral manner and by refocusing the discussion when irrelevant topics are introduced. The key to obtaining data effectively lies in the interaction of the group members with each other. The moderator uses questions that are open-ended to allow flexibility in the group discussion. The questions and discussion guide, however, are planned carefully in advance to achieve a proper balance between open discourse and focusing on relevant topics. 7Pope, Catherine, and Nicholas Mays (eds.), Qualitative Research in Health Care, 2nd Edition, BMJ Books, London (2000), pp. 20-29, 75-88. 8Morgan, David L., The Focus Group Guidebook, Focus Group Kit, Volume 1, Sage Publications, Thousand Oaks, CA (1998), p. 41. 9Morgan (1998), pp. 41-42. 10Michael Perry, Lake Snell Perry & Associates, "Medi-Cal and Healthy Families: Focus Groups with California Parents to Evaluate the Medi-Cal and Healthy Families Programs," prepared for the Kaiser Family Foundation, January 2001 (available at www.kff.org). B. Recruitment and Enrollment Prior to undertaking any activities to recruit focus group participants, the project team obtained approval from the UC Berkeley Committee for the Protection of Human Subjects, as required by federal law, on detailed procedures for identifying and recruiting participants, obtaining informed consent, and protecting participants' identities. Participants gave written consent for the use of data that they provided and were promised that their participation and individual data would be kept confidential within the extent of law.

Case managers who work for, or under contract with, claims administrators, employers, and health care providers. The materials could be developed in consultation with a cooperative, multipartite task force. The members of the task force should probably be carefully selected by the Commission to avoid unnecessary conflicts and disagreements. Members of the panel could include persons who represent the professional groups to be described in the materials, as well as representatives of injured workers and employers. B. Respectful Attitudes Towards Injured Workers Injured workers in California must navigate a system that is fraught with complicated 20 rules and procedures, and they are often treated disrespectfully by others. Those with permanent disabilities sustain significant financial losses even after receiving workers' 21 compensation benefits, and many are unable to find jobs that pay well. This study shows that injured workers also face suspicion regarding the symptoms they describe and their needs or preferences about staying off work. This suspicion and negative stereotyping of injured workers can hinder recovery. In response to suggestions from focus group participants for improving attitudes towards injured workers, members of the Project Advisory Committee supported the concept of a public information campaign to increase respect for injured workers. They also made specific suggestions regarding the content and design of messages in such a campaign (see , above.) To help dispel negative attitudes towards injured workers and thus promote healing, we recommend that the Commission develop methods and plan activities to promote respectful treatment of injured workers. This could be accomplished in consultation with the task force described in Recommendation A. Methods could include, for example: