Therapists’ Perspectives on Using the Worker Role Interview in Spinal Cord Injury Rehabilitation in Bangladesh

Setting and Participants Recruitment

This study was undertaken in the spinal rehabilitation service at CRP in Bangladesh. OTs working at CRP were invited to participate in this study via a generic email and invitation posters in common staff areas within the facility. Eligibility criteria included:

• prior experience of conducting vocational assessment at CRP;

All the OTs working in the SCI unit (n = 5) expressed interest in taking part in this study, and received WRI training provided by the first author (MMU) as below.

Preparing OTs to Use the WRI in Their Practice

The first author conducted WRI training for interested OTs at CRP. The training sessions included a 30-min PowerPoint presentation on the overview and administration of the WRI 10.0 (Braveman et al., 2005), followed by group sessions to discuss the language of the interview; to watch and discuss a video on WRI administration (produced by the University of Illinois-Chicago, USA); a practice session with a volunteer patient; and one-to-one sessions with the lead author regarding practice preparation. The therapists were given a Bangla-translated copy of the WRI-recommended questions used in an earlier study (Ullah et al., 2025), and the WRI manual (Braveman et al., 2005) was provided for further clarification and reference. The five OTs on the SCI unit then had three months to practise using WRI with their patients, prior to being invited to participate in an interview. The first author then contacted each of these five OTs to check whether they had used the WRI interview and if they were still willing to be interviewed about their experience. A detailed participant information statement and consent form were provided to explain the study. Four of the five WRI-trained OTs from the SCI unit were available at this time and gave written informed consent to participate in an interview about using WRI in their practice with patients with SCI.

Data Collection Interview

Each WRI-trained OT participants took part in a face-to-face interview with the first author at a mutually agreed and convenient place. The participant information sheet emphasized that these interviews were confidential, conducted independent of normal work activities, and that the views expressed would be de-identified and carry no job-related consequences.

Each semi-structured interview was conducted by the first author. At the beginning of each interview, practice-related information was collected, including the participant's years of work experience since graduation, the length of their experience, average SCI caseload/week in SCI rehabilitation, familiarity with the WRI, and confirmed their prior experience interviewing patients with SCI about work participation.

The first author used an interview guide (See supplementary information) to explore therapists’ views about the WRI and facilitate relevant follow-up questions. This interview guide was developed by the research team, informed by the literature on the usefulness of assessment tools in Occupational Therapy practice (Toomey et al., 1995; Yngve & Ekbladh, 2015). These questions focused on the challenges and strengths of the WRI regarding administration, environment, patient responses, the content of the questions, suitability within the cultural context, practical considerations or issues, and potential for use in Bangladesh. Participants were also asked to reflect on their vocational assessment practice before and after using WRI. Interviews were conducted in Bangla, the native language of the participants and the first author, ranged in length from 45 to 55 min, and were audio-recorded. Participants were informed that they could add further information later or amend any sections of their recorded interview. One participant sent an email with added notes based on reflections about her experience that she had not mentioned during the interview.

Data Analysis

Interviews were transcribed from audio-recording in Bangla, and then translated into English by the first author for data analysis. Audio-recorded interviews were listened to multiple times to minimise any loss of meaning of the interview data during the translation process. The thematic analysis process, described by Braun and Clark (Liamputtong, 2013), was followed to generate the study findings. MMU and RS developed initial coding independently, met regularly to identify the emerging initial themes. All three authors then reviewed the emerging themes based on the initial coding; and reached consensus by defining and naming the themes through regular discussion.

Researcher Positionality and Reflexivity

First author (MMU) is an Occupational Therapist with 12 years of practice experience at the time of this study, which was part of his PhD project. The study setting, CRP int Bangladesh, was his previous workplace of MMU, two years before the interviews. MMU is a native Bangla speaker, had prior work experience with SCI patients, and teaching WRI to practising occupational therapists. During data collection, the MMU recorded technical decisions, understandings of prior assumptions, beliefs, and challenges with participants in his reflective journal following each interview. Author 2 (EF) and Author 3 (RS) were the academic supervisors. Both are Australian women with backgrounds in occupational therapy, expertise in qualitative research, rehabilitation, and work-related research. The research team critically reflected on their views and beliefs in relation to the findings through regular open discussions during the analysis and manuscript development phases, as well as the writing of personal reflection notes. Findings used verbatim quotations to support the interpretation.

Participants Overview

Four OTs working in the spinal unit at CRP participated in this study. Their background information is summarised rather than individually described to protect their anonymity. The participants were all working full-time in permanent positions and had between one and a half and over 10 years’ experience working with people with SCI. They had an average caseload of seven patients per day as well as regular administrative responsibilities. All participants had used the WRI to interview at least three persons with SCI, with a total of fifteen WRI interviews with male patients having been completed.

Themes on the Usefulness of the WRI

Thematic analysis of OT participants’ views on the usefulness of the WRI generated four key themes: Supports agency for patients to express themselves and work possibilities; Initiates self-inquiry about the prospects of working; Facilitates understanding of patients beyond their injury; and Contextualising the interview for local practice (Figure 1). Each of these is discussed in more detail below with illustrative quotes from participants.

OPEN IN VIEWER

Figure 1.

Themes on the usefulness of the WRI for SCI.

Supports Agency for Patients to Express Themselves and Work Possibilities

The interviewed OTs identified that the WRI prompts discussion around patients’ expectations of themselves as workers, and consideration of their future participation in work. They described finding that patients shared their views about work during the interview, and particularly when they were able to facilitate a conversation:

“­In the WRI sessions, I have found him an independent individual, not under my control. During the treatment sessions, he is under my control, he listens to what my instructions are. But during the interview, I have seen them make their voice heard. I have seen some ‘empowerment’ type things happen.” (OT 1)

Initiates Self-Inquiry About the Prospects of Working

OTs described the interview content as providing a trigger for thoughts about work participation after SCI, which seemed to guide patients to develop expectations and initiate analysis regarding their future work participation process.

“I think the patient gets a “stimulation” for vocational decision-making from the interview questions. I can see this stimulation happening while I am conducting the interview.” (OT 2)

Facilitates Understanding of the Patients Beyond Their Injury

This theme highlights the influence of the use of the WRI on the OTs practice, and how they found their role shifted from one of prescriber to that of facilitator, enabling more individualised practice. OTs reported that using the WRI in their practice led them to view patients holistically, which helped them establish communication in a more meaningful way and identify relevant, in-depth information about their clients. After using the WRI, OTs identified that they had changed their understanding of their patients’ perspectives. Knowing more about the patients and their individual feelings, thoughts, and hopes made the OT more appreciative of the patients’ sense of the meaning of work.

“I think it contributed to some changes in my perspective. In the past, all my vocational assessments were very short-cut. Very structured and about physical capacity. There was no scope to know his mental status, why he is interested in a particular training, or why he is not interested. After doing the WRI, it also made me realise that as a therapist I should also focus on these areas.” (OT 3)

Contextualising the Interview for Local Practice

Although OTs provided positive feedback on the experience of using the WRI in their practice, they also identified several aspects of the tool which needed to be better contextualised for use in Bangladesh. OTs identified culturally based issues arising from both patients’ responses and their professional judgment and addressed these via contextualising the guided question and concepts.

All OTs mentioned difficulties exploring several WRI items related to language. For example, a phrase such as ‘perception about the boss’ was not culturally meaningful, as most of this SCI population came from a background of self-managed or self-employed work. There were also some issues around terminology related to the concepts of ‘routine’ and ‘leisure’, which require further clarification or contextualisation:

“Work routine, interest, and how they spend leisure time were hard to communicate. For a patient who was a farmer, I asked about leisure, and he said, ‘What is leisure for me? I work all day. If I go outside, I am at the farm, when I am inside, I work with my chickens and cattle.’ They find it difficult to identify their leisure hours.” (OT 2)

Therapists’ Understanding of Patients’ Perspectives

The information gathered when using the WRI enhanced the OTs’ understanding of their client's point of view, particularly in relation to psychosocial factors beyond the injury itself. This is important since implementing strategies that address psychological factors such as hope, future orientation, motivation, and self-efficacy are linked with improved employment and psychological well-being outcomes following SCI (Bloom et al., 2020). Further, it supports previous research findings that accessing the patients’ ‘voice’ and views about work participation assists therapists to understand their patients’ worker roles and how their volition, habits, and perceptions about social and physical environments might influence their desired work-related rehabilitation outcomes (Egan et al., 2015; Fisher, 1999). Since a matrix of psychological and environmental factors influence these outcomes, therapists’ understanding of these factors is necessary to creating opportunities for returning to work after SCI (Hilton et al., 2018). The importance of understanding the psychological and environmental aspects is supported by previous WRI studies with other client groups, including those with musculoskeletal disorders and mental disorders (Aas et al., 2011; Ekbladh & Sandqvist, 2015). Furthermore, engaging with patients in conversations about return to work or education during inpatient rehabilitation can also create feelings of hope and guide intervention options accordingly (Analytis et al., 2025; Ramakrishnan et al., 2016).

Contextualisation of WRI

The WRI is a tool that enables users to look beyond simply functional capacities (Fisher, 1999). Therefore, it was suitable for addressing the identified practice gap in work-related assessments used at CRP in Bangladesh. However, there are also contextual challenges that need to be addressed, such as some of the tool language and the presence of family members during the interview. The concept of ‘boss’ or ‘co-worker’ in WRI was not usually relevant if the person works independently on their land. The routines of people working in traditional agriculture farming, a group commonly represented by SCI patients, change significantly throughout the year based on the cycle of seasons, e.g., planting seedlings, irrigation, and harvesting. The components ‘perception of Boss’ or ‘work setting’ within the WRI constructs have also been previously identified as difficult to translate in other studies (Fenger & Kramer, 2007; Forsyth et al., 2006; Koller et al., 2011).

The value of involving family members in a more meaningful way to support shared expectations as part of the rehabilitation process has been previously identified (Jeyathevan et al., 2020). Due to the lack of a social security system in Bangladesh for persons with disabilities and the absence of rehabilitation services for persons with SCI at the community level, engaging all those involved after discharge can enhance realistic discussion and understanding of future work prospects, and common issues and challenges (Jeyathevan et al., 2020). Therapists identified the need to use careful reasoning and judgment about when to involve family members in the discussion of the work plan.

Study Methodological Quality

Several factors should be considered when interpreting the findings for practice. The four therapists who participated in this study were recruited from CRP, the specialised rehabilitation centre service in Bangladesh. . Fifteen OTs were practising in the service at the time of this study, of whom only five of them worked with people with SCI and participated in WRI training, and were eligible for interview. This sample is relatively small but represents most occupational therapists providing rehabilitation services for people with SCI at CRP. Their experience of interviewing using WRI was solely with male inpatients, this being the most common patient group in this service. Hence, the findings are directly relevant to occupational therapy practice in the rehabilitation service for men with SCI in Bangladesh, and may also be transferable to contexts where occupational therapy practice is similar.