A Model of Behaviour Change in Housework for Women with Upper Limb Repetitive Strain Injury

Upper limb repetitive strain injury (RSI) is a costly disease. Evidence indicates biomechanical risk in housework that contributes to this cluster of conditions among women. Although there is consistent evidence indicating the importance of conducting ergonomic education to monitor the mechanical exposures for better musculoskeletal health, there is limited research on understanding behaviour change in housework for women with upper limb RSI. Occupational therapy has an important role in facilitating behaviour change in housework for women with upper limb RSI, to minimise their exposure to biomechanical risk in housework through ergonomic education. In a hand therapy outpatient clinic in an acute hospital in Singapore, such education is usually conducted by therapists for women with upper limb RSI on a one-to-one basis; planning is based on the clinical experience of individual therapists rather than on a specific theory. The purpose of this thesis is to construct a model of behaviour change in housework for women with upper limb RSI, to guide the planning of such education within a hand therapy outpatient clinic in a Singapore acute care hospital. Framed by a client-centred approach, a central philosophy of occupational therapy, which indicates the importance of ‘listening and communicating’ with clients at all stages of intervention and considering the importance of making therapists’ tacit knowledge explicit while planning an intervention, two grounded theory studies (Study I and Study II) adopting the constructivist approach outlined by Charmaz (2009a) were conducted to construct the model. Both studies collected data through in depth interviewing. Study I investigated the perceptions of 15 women with upper limb RSI who had received ergonomic education on housework conducted by occupational therapists. The study found that even though women perceived a change in housework was necessary and possible, they would not make a change if they perceived it as emotionally unacceptable when it was disruptive to their habits and routines developed according to the meanings they attached to housework. Also, the factors used by each woman to make decisions on housework were different, according to their specific situations and experiences. The study showed the important effect of the women’s self-identity and social role as a homemaker on how they considered advice from the health professionals on making changes in housework. From the findings of the study, a conceptual framework was constructed on their decision making in housework. Study II investigated the clinical reasoning process of 14 occupational therapists who had conducted such education. There were three main findings of this study. First, therapists perceived that clients go through different stages before they finally incorporate recommended changes into their routines. Second, therapists perceived doubts from their clients regarding their credibility to provide advice on housework. Third, therapists found the limited resources within their clinical environment a challenge for them to ‘listen and communicate’ with their clients (a major component of client-centred approach). The study showed the effect of therapists’ professional roles and personal roles on their interaction with their clients, hence their clients’ willingness to change. From these findings, a conceptual framework was constructed on the therapists’ clinical reasoning process. A model of behaviour change in housework for women with upper limb RSI was then constructed by integrating the major concepts from these two frameworks. There are five major constructs in this model. They include the clinical environment, client-therapist interaction, emotional attachment to housework, cognitively informed decisions, and stages of change. With a comparison of the findings from Study I and Study II, a gap in therapists’ clinical reasoning process was identified. The first major issue was that therapists lacked a deeper understanding of the meanings women with upper limb RSI attached to housework. Another issue was the time pressure and space limitation within an acute clinical environment which affected the client-therapist interaction that was crucial in clients’ willingness to make changes in housework, according to the therapists’ advice. Based on the constructs of the model and the findings of the two grounded theory studies of women with upper limb RSI and the occupational therapists who conducted ergonomic education on housework for them, an assessment was then designed as an initial step to address these issues. A pilot study using a quantitative methodology was conducted to implement this tool for a group of women with upper limb RSI, who were referred to a hand therapy outpatient clinic in an acute hospital in Singapore. The pilot study provided preliminary evidence on the validity of the assessment and its consistency with the model of behaviour change in housework for women with upper limb RSI. The present research has identified major findings related to the differences in social roles, identity and values caused by a generational gap between women with upper limb RSI and the therapists who conducted ergonomic education for them. Women who participated in the present research are mainly married with children. They considered their role as a homemaker salient in representing their role as a mother, a wife and a woman. As such, the housework habits and routines they developed through the years become a behavioural representation of these identities. In contrast, therapists who conducted ergonomic education for these women are mostly single, living with their families. They did not attach deep meanings to housework and did not consider housework as representation of their self-identity. The present research found that during ergonomic education, it was mainly the therapists’ professional identity that directed how they interacted with clients. As such, they only started to consider the clients’ perspective of housework when clients refused to change. Therapists may not have considered the full range of meanings that their clients attached to housework when interacting with them. While the present research was framed by a client-centred approach, the findings of the studies in this research confirmed its importance. There are three implications for practice. First, therapists need to be trained to gain a deeper understanding of the meanings their clients attach to housework and how to move their intervention towards a client-centred approach, within a clinical environment that is under time pressure. Second, the use of an assessment to provide information on clients’ perceptions of and readiness to making a change in housework could be a first step towards better interaction between the therapists and their clients. Third, program evaluation could be the next step to gain organisational support for the intervention to move towards a client-centred approach according to the model. This research is significant not only because it provides a framework of intervention for this particular group of women, but it also sets an example of how research could be conducted to improve other interventions within occupational therapy practice, by listening to both the voices of clients and their therapists