Sustainable work after cancer: Exploring long-term journeys from a salutogenic perspective

Abstract

Introduction: Research on the impact of cancer on people's work-life has shown that the majority of persons who survive cancer (PSC) are successful in their return to work (RTW). However, almost a third of employed individuals of working age fall out of work during the first six years after cancer treatment. Retaining work after cancer is dependent on cancer-related, work-related, and personal factors. Those who have had a tendency to fall out of work are those who have experienced severe cancer treatment or those who have physically demanding work. Factors such as high age, being a woman, and low education or income level, have also moderated the likeliness for RTW. Still, little has been done to investigate successful RTW after cancer and the critical resources to make that happen. Also, previous research on RTW has mainly included only the initial phases less than five years after cancer. Aim: Our overall aim was to explore RTW experiences in a long-term perspective more than five years after cancer. The aims of the first study were a) to investigate RTW factors and the long-term perspectives involved in sustainable RTW and b) to explore experiences of PSC after they had re-established normality and returned to sustainable work. The second study's aims, derived from the results in the first study, were: a) to explore the tensions experienced by long-term cancer survivors during cancer treatment and RTW and b) to investigate the resources they utilized to resolve the tensions. The third study's aim, also derived from the first study's results, was to describe the patterns of labor-force participation, working hours, job changes, and education for nine consecutive years among women and men who had survived cancer, and to compare those patterns with matched controls. Methods: Three studies were performed and interlinked in this thesis. The first two studies were based on qualitative data and in-depth interviews. Four men and four women aged 42–59 years, who had worked successfully at least three years or more after cancer, participated in eleven interviews, re-interviewing three participants included. The time since their last treatment was nine years on average. Interpretative Phenomenological Analysis (IPA) was utilized for the first study. For the second study, the framework of Antonovsky's Salutogenic Model of Health (SMH was used to re-analyze the interview data from the first study. An advisory team of seven members with diverse cancer experiences contributed as co-researchers for both studies. In the third study, RTW patterns were described as they appeared in a controlled registry study and a larger population. The Norwegian Registries of Cancer provided information about 2,629 PSC who were diagnosed with cancer in 2004/2005, aged 30-50 years, who were working at the time of diagnosis, and were alive and without recurrence of cancer for a longer time than the investigated period (10 years). These PSC were monitored for nine consecutive years after the cancer diagnosis and compared to 5,258 unique controls, matched by age, education level, and working hours. The variables of employment status, working hours, job changes, and education were stratified on gender and were analyzed using descriptive statistics. Results: Results from the interviews revealed a five-phased process model that describes the RTW processes. Individual trajectories showed a large variety of adaptations and duration of RTW processes. Critical for success was personal mastering skills. These skills included accepting the situation and changes but never giving up the aim of RTW following altered abilities and new ways of prioritizing life. Most important for achieving sustainable RTW was the participant's inner strength and decisiveness. Also significant were surrounding and supportive relationships at home and at work, opportunities to make individual work adjustments, and a financial foundation that allowed the participant to make choices. This thesis confirms that the timeframe of effects from cancer treatment on work-life goes beyond the first 5 years after the cancer diagnosis. The long-term horizon on achieving sustainable work showed the first attempt to RTW does not always last and that occupational change and re-education may be necessary. Among a larger population, about 85% of PSC managed to RTW during the first 2-4 years, but female PSC downgraded working hours or quit work more often than male PSC. Conclusions: Crucial for achieving sustainable work is never to let go of the decision to return to work and have a combination of personal and contextual resources available to make necessary adjustments in accordance with the effects of treatment and a renewed situation. The process of achieving sustainable work after cancer may last for many years, and the first attempt to RTW does not always last. Sometimes, a total change of occupation or a new education can be essential in establishing sustainable work. Implications: The five-phased process model described in Article 1 can be useful for increased understanding of the situation and identifying needs for support in individuals' journeys of RTW after cancer. Social welfare systems should be flexible to meet diverse individual needs during the RTW process, which can last for many years after cancer treatment. Further investigations, multivariate analysis on registry data and intervention studies for further testing and deepening of the five-phased process model may provide valuable knowledge.