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Validation of Lam assessment of employment readiness (C-

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J Occup Rehabil (2006) 16:697–705
DOI 10.1007/s10926-006-9050-3
ORIGINAL PAPER

Validation of Lam assessment of employment readiness

(C-LASER) for Chinese injured workers

Henky Chan · Cecilia W. P. Li-Tsang · Chetwyn Chan ·

Chow Shing Lam · Karen Lo Hui · Christine Bard

Published online: 25 October 2006

C Springer Science+Business Media, LLC 2006

Abstract Introduction: The Stage-of-Change Model offers a theoretical framework for under-
standing people’s intention to change. The Lam Assessment of Stages of Employment Readiness
(LASER) was developed to measure one’s psychological readiness to return to work after an
extended period of unemployment due to disability. Method: The present study aimed to validate
the Chinese version of LASER using a sample of Chinese industrial injured workers. Ninety sub-
jects with previous history of work-related injuries participated in the study. Results: Principal
component analysis revealed a two-factor solution which was found different from the original
three-factor structure of LASER. Test retest reliability (ICC) ranged from 0.55 to 0.79. Findings
suggested that human capital factors of the workers did not seem to contribute significantly
to the participants’ readiness to return-to-work. Instead, the perceived pain levels became the
major contributing factor. Discussion: The Chinese version LASER was useful for reflecting
the readiness of injured workers returning to work. However, the pathology associated with the
injuries together with the workers’ compensation system might influence the process of change
which warrants further study area.

Keywords Stages of Changes model on employment readiness . Vocational rehabilitation .

Return to work . Injured workers

H. Chan · C. W. P. Li-Tsang
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, HK, China

C. Chan
Ergonomics and Human Performance Laboratory, Department of Rehabilitation Sciences,
The Hong Kong Polytechnic University, HK, China

C. S. Lam · C. Bard
Institute of Psychology, Illinois Institute of Technology, Chicago, US

K. L. Hui
Hong Kong Worker’s Health Centre, HK, China

C. W. P. Li-Tsang (
)
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, H K, China
e-mail: rscecili@inet.polyu.edu.hk
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698 J Occup Rehabil (2006) 16:697–705

Introduction

Work-related injuries cost consumers and society directly and indirectly, in terms of compensa-
tion, loss of working days, costs of hiring and training new employees or temporary workers,
loss of profits, increased overhead costs during work interruption, and decreased employee
morale and efficiency [1]. Previous studies indicated that only a small percentage of injured
workers return to gainful employment, and often to a less demanding job [2]. Many factors
were found to affect the likelihood of return-to-work. These include social, psychological, hu-
man capital and economic factors [2, 3]. Among them, individual’s readiness to return-to-work
was found to play a crucial role in predicting injured workers’ success in resuming a work
role.
The stages-of-change model proposed by Prochaska and DiClemente [4] offers a theoretical
model to illustrate the behavior of injured workers as they move through the process of recovery
from injuries and returning to work. This model suggests that the change process varies at differ-
ent stages. Cognitive and experiential processes are more salient in the early stages-of-change,
and behavioral processes become increasingly important and frequent during the later stages [5].
Prochaska, DiClemente, and Norcross [4] suggested that efficient behavioral change depends on
doing the right things (processes) at the right times (stages). It is therefore important to assess the
stage of an individual’s readiness for change and to match interventions accordingly. According
to Prochaska et al. [4], any type of behavioral change has five stages which are connected to one
another in a spiral manner. They are pre-contemplation, contemplation, preparation, action, and
maintenance. In the context of injured workers and their return-to-work, the pre-contemplation
stage is characterized by the workers not having the intention to work in the foreseeable future.
Behaviorally, workers might feel that they are being “forced or coerced” into attending a work
program, and express a desire to change the environment or the system, not themselves [6]. The
contemplation stage is characterized by the workers becoming aware of the problem, beginning
to consider the prospects of change, but not having made a commitment to change. It is common
for them to seesaw and weigh up the pros and cons of leaving the compensation system to work.
The preparation stage is when the workers intend to go back to work in the near future and have
unsuccessfully taken this action in the past. They may have made efforts to look for work, but not
yet met the criteria for employment. In the action stage, the injured workers are involved in overt
modification of the problem behavior, and hence ready to return-to-work. In the maintenance
stage, the workers put effort into consolidating the gains, preventing injury, and continuing their
employment.
McConnaughy et al. [7] developed the first stage-of-change measure for studying a group
of participants undergoing psychotherapy. The Stages-of-Change Questionnaire (SCQ) was a
32-item instrument which contained four subscales: pre-contemplation, contemplation, action,
and maintenance. These four subscales were shown to generate major and minor stage-of-
change profiles for the participants. The seven major profiles were labeled: [1] Decision Making,
[2] Maintenance, [3] Participation, [4] Pre-Participation, [5] Non-Contemplative Action, [6]
Immotive, and [7] Uninvolved. The two minor profiles were labeled: [1] Reluctance, and [2]
Non-reflective Action. McConnaughy et al. [7] further argued that these profiles were useful for
describing participants’ different patterns of involvement in each of the stages.
In a replication study conducted by McConnaughy et al. in 1989 [6], a similar four-subscale
structure was maintained. However, a new “contemplation” profile was identified. Blais and
Rossi in 1992 compared and synthesized five studies reporting cluster profiles of the SCQ
across four problem areas: psychotherapy, adolescent cigarette smoking acquisition, alcoholism
treatment, and sun exposure. In two of the four problem areas, 10 stages-of-change cluster
profiles were identified.
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J Occup Rehabil (2006) 16:697–705 699

Lam, McMahon, Priddy and Gehred-Schultz [8] adapted the SCQ and developed the Change
Assessment Questionnaire (CAQ) for use on a group of clients with acute traumatic brain injuries.
Later, Lam, Chan and McMahon [9] found that the CAQ possessed a similar factorial structure
to that reported by McConnaughy et al. [6].
The Lam Assessment of Stages of Employment Readiness (LASER) was developed later,
in 1997, and was found relevant for use on workers who had gone through the return-to-work
process [4]. Following its success in application to those with traumatic brain injuries undergoing
rehabilitation [9], the stage-of-change model was further utilized on the unemployed persons
[10], while most of the job services at that time were unable to allow flexibility in matching
clients’ readiness to work due to a lack of instruments to identify clients’ readiness.
LASER contains 14 items which describe behaviors in the pre-contemplation (6 statements),
contemplation (4 statements) and action stages (4 statements). The workers are asked to rate
each item on a five-point Likert Scale with “1” indicating strongly disagree to “5” indicating
strongly agree. The scores are then added and allocated under different sub-scores representing
the corresponding stages as forming a continuous measure. The highest sub-score will represent
a subject’s tendency towards the corresponding stage. Subjects at the pre-contemplation stage
do not see unemployment as a problem, and are often not interested in working, or believe that
they cannot work. Subjects at the contemplation stage begin to consider the pros- and cons- of
working, but they have not yet participated in any related action such as job searching. Subjects
at the action stage have decided to work and engage in behaviors to increase the probability of
being hired.
This study aimed to translate the LASER into a Chinese version (C-LASER) for assessing the
stage-of-changes among the Chinese injured workers. The validation process included collecting
evidence for its content-related, construct and predictive validity. The test-retest reliability of
the C-LASER was also estimated. The results of this study would provide the basis for using
the Chinese version of LASER in return-to-work programs and also allow researchers to further
explore the relevance of using the stage-of-change model to describe the readiness to return-to-
work among Chinese workers.

Methods

The LASER was directly translated into Chinese by a qualified translator. Seven rehabilitation
practitioners with experiences working with injured workers were recruited as members of an
expert review panel. There were six occupational therapists and one social worker, with a mean
work experience of 9.1 years (S.D. = 4.1). The panel was requested to review the equivalence
and clarity of the Chinese translation of the LASER. This was followed by evaluating the
relevance and representation of the test content. Two review forms were developed to facilitate
the work of the panel members. There was a total of 14 items which the members were to rate
on a five-point Likert scale with “1” representing “most disagree” and “5” representing “most
agree”.
The panel members assigned either “4” (agree) or “5” (mostly agree) ratings to nine out of the
14 items in the translated version. There were four items which received a “3” (neutral) rating and
one item which received a “2” (disagree) rating. The comments of the panel members indicated
that the major concerns were with the clarity of the translations of the expressions “might be
ready”, “doing something” and “leave me alone” and the interpretation of the phrases “nothing
I can do” and “I think I should” in Chinese. These items were subsequently modified according
to the recommendations offered by the panel members. The evaluation of the content relevance
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700 J Occup Rehabil (2006) 16:697–705

and representativeness were rated with either “4” or “5”. Hence, no further modifications of the
item contents were needed.
The draft version of C-LASER was modified according to the comments gathered from the
two panel reviews. A field test was conducted to collect data to assess the test-retest reliability,
the construct and predictive validity of the revised C-LASER. Convenient sampling method was
used to recruit the subjects from a return-to-work program offered at the Hong Kong Workers’
Health Centre. A total of 90 participants volunteered to join the study. Thirty-eight were female
(42.2%) and 52 male (57.8%). Their mean age was 42.1 years (S.D. = 9.7). Thirty of them
(33.3%) had 1 to 6 years of education, 27 (30.0%) had 7 to 9 years and another 33 (36.7%) had
10 years or above. Thirty-two subjects (35.6%) were suffering from low-back pain, 22 (24.4%)
were suffering from upper-limb traumatic injuries, 13 (14.4%) were suffering from lower-limb
traumatic injuries, 11 (12.8%) were suffering from repetitive strain injuries and 12 (13.8%) had
other types of injuries such as head injuries, and chest injuries. Their mean loss of earning
capacity as assessed by the Labour Department was 15.6% (S.D. = 23.3) and their previous
mean monthly income was HK$11906.3 (S.D. = 6378.19).
The C-LASER was administered to the participants at the time when they joined the return-
to-work program. Two questions with a 1-to-10 scale on subjects’ self-perceived efficacy and
confidence with regard to returning to work, and a Short Form 36 (SF-36) were also administered.
The sequence of the tests was randomized to avoid any potential order effects which might
confound the results. The C-LASER was conducted during a briefing session of the return-to-
work program and on admission to the program in order to collect evidence of the test-retest
reliability of the instrument. The period between the two test administrations ranged from 7 to
14 days, and no treatment was provided in between the two assessment occasions.

Results

Item analysis revealed item difficulty indices ranging from 0.42 to 0.92, while item discriminative
indices ranged from 0.17 to 0.58 (Table 1). Principal component analysis with Varimax rotation
was used to test the groupings of the 14 C-LASER items. The results indicated a two-factor
solution which accounted for 47.7% of the total variance (Table 2). Factor 1 items (n = 8)

Table 1 Item difficulty and item discriminative index of the C-LASER items

Items Item difficulty index Discrimination index

(Contemplation) Item 1. 0.75 0.50

(Action) Item 2 0.67 0.50
(Contemplation) Item 3 0.92 0.17
(Pre-Contemplation) Item 4 0.71 0.50
(Action) Item 5 0.79 0.42
(Contemplation) Item 6 0.63 0.58
(Pre-Contemplation) Item 7 0.73 0.46
(Pre-Contemplation) Item 8 0.42 0.33
(Contemplation) Item 9 0.88 0.17
(Pre-Contemplation) Item 10 0.65 0.38
(Action) Item 11 0.73 0.38
(Pre-Contemplation) Item 12 0.63 0.42
(Action) Item 13 0.77 0.46
(Pre-Contemplation) Item 14 0.88 0.25

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J Occup Rehabil (2006) 16:697–705 701

Table 2 Principal component

analysis with varimax rotation (n = Items Factors
90)
Factor 1 Factor 2
Item 1. 0.77 − 0.20
Item 2. 0.83 < 0.001
Item 3. 0.44 − 0.45
Item 4. − 0.16 0.72
Item 5. 0.81 − 0.12
Item 6. 0.70 − 0.13
Item 7. − 0.22 0.74
Item 8. − 0.44 0.12
Item 9. 0.35 − 0.49
Item 10. < 0.001 0.54
Item 11. 0.55 − 0.12
Item 12. < 0.001 0.40
Item 13. 0.77 − 0.26
Item 14. − 0.26 0.77

seemed to represent those at the contemplation and action stages, whilst factor 2 items (n = 6)
appeared to represent those at the pre-contemplation stage.
Test retest reliability was estimated by correlating the scores of the two consecutive adminis-
trations of the C-LASER to the same group of participants. The reliability coefficients (intra-class
correlation, ICC) on the item scores of the 14 items ranged from 0.55 to 0.79 (Table 3). There
was a total of three items, 7, 10 and 12, which had ICC values lower than 0.60. The internal con-
sistency estimated by Cronbach’s Alpha for factor 1 items was 0.85, and that for factor 2 items
was 0.69. The mentioned three items (i.e. 7, 10, 12) under factor 2 with ICC values lower than
0.60 were removed from C-LASER and then with internal consistency re-calculated. However,
Cronbach’s Alpha decreased from 0.69 to 0.50. Therefore, the three items were retained.
Cluster analysis with Ward’s method was used to further test the usefulness of the C-LASER
subscales. The results suggested a two-cluster solution based on the factor sub-scores. Fifty-four
subjects (60.0%) were found in cluster 1, and 36 (40.0%) were found in cluster 2. No significant
differences were found between the two cluster groups in terms of demographic characteristics

Table 3 Test-retest reliability

coefficients of C-LASER Items
(ICC) Intraclass coefficients p-value 95% C.I.

Item 1. 0.79 0.002 0.404–0.925

Item 2. 0.74 0.005 0.283–0.909
Item 3. 0.77 0.002 0.370–0.920
Item 4. 0.70 0.01 0.154–0.893
Item 5. 0.64 0.03 − 0.010–0.872
Item 6. 0.69 0.01 0.129–0.890
Item 7. 0.59 0.04 − 0.148–0.855
Item 8. 0.69 0.01 0.129–0.890
Item 9. 0.72 0.008 0.211–0.900
Item 10. 0.59 0.04 − 0.130–0.857
Item 11. 0.73 0.007 0.240–0.904
Item 12. 0.55 0.06 − 0.252–0.842
Item 13. 0.63 0.03 − 0.020–0.871
Item 14. 0.60 0.04 − 0.108–0.860

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702 J Occup Rehabil (2006) 16:697–705

Table 4 Demographic characteristics of the participants classified under the two clusters

Items Clusters

Cluster 1 (n = 54) Cluster 2 (n = 36)

Sex (F:M) 21 : 33 17 : 19
Mean Age 43.7 (SD = 10.2) 39.7 (SD = 8.4)
Educational Level 31.5% (1 to 6 years) 36.1% (1 to 6 years)
27.8% (7 to 9 years) 33.3% (7 to 9 years)
40.7% (10 years or above) 30.6% (10 years or above)
Factor 1 Sub-score 33.1 (SD = 3.4) 28.4 (SD = 4.2)
Factor 2 Sub-score 11.7 (SD = 2.5) 17.5 (SD = 3.0)
SF-36 Physical Functioning 22.6 (SD = 4.5) 19.6 (SD = 4.1)
SF-36 Role Physical 5.2 (SD = 1.4) 4.7 (SD = 1.0)
SF-36 Bodily Pain 6.2 (SD = 1.8) 5.0 (SD = 1.7)
SF-36 General Health 16.0 (SD = 3.4) 15.1 (SD = 3.0)
SF-36 Vitality 13.6 (SD = 5.1) 12.3 (SD = 4.1)
SF-36 Social Functioning 6.3 (SD = 1.7) 4.9 (SD = 1.7)
SF-36 Role Emotional 4.0 (SD = 1.2) 3.8 (SD = 1.1)
SF-36 Mental Health 17.8 (SD = 5.8) 16.4 (SD = 5.7)
SF-36 Reported Health Condition 2.7 (SD = 1.3) 2.7 (SD = 1.1)
Successful Employment Rate within 6 months 53.7% 38.9%
Self-reported confidence in job seeking (1–10) 7.50 (SD = 2.11) 4.97 (SD = 2.36)
Self-reported advocacy in job seeking (1–10) 5.77 (SD = 2.29) 4.31 (SD = 2.29)

such as sex (chi-square, p = 0.43), educational level (chi-square, p = 0.58) and types of
injury (chi-square, p = 0.20) except marginal difference was found for age (F[1,85] = 3.69,
p = 0.06)..
Multivariate analysis of variance was conducted to compare the differences in factor sub-
scores between the two clusters. Significant group effects were identified whereby participants
classified under cluster 1 had significantly higher sub-scores on factor 1 on items representing
contemplation and action stages, while they had lower sub-scores on factor 2 than their cluster 2
counterparts (Pillai’s Trace, F[2,87] = 61.15, p < 0.001). It would seem cluster 1 describes the
characteristics of participants who are ready for action, and cluster 2 shows the characteristics
of pre-contemplators.(Table 4)
Further multivariate analysis of variance was then conducted to compare the differences in
SF-36 sub-scores between the two clusters. Significant group effects were identified whereby
participants classified under cluster 1 (the Actioners) had significantly higher SF-36 sub-scores
than those under cluster 2 (the Precontemplators) (Pillai’s Trace, F[9, 78] = 2.38, p = 0.02).
Further univariate analysis using Bonferroni correction for adjustment of type I error (al-
pha = 0.05/9 = 0.006) revealed significant differences in physical functioning (F[1, 86] = 9.87,
p = 0.002), bodily pain (F[1, 86] = 9.22, p = 0.003) and social functioning sub-scores (F[1,
86] = 15.87, p < 0.001) between the two cluster groups, with subjects in cluster 1 demon-
strating better (higher) scores in above all three aspects. Multivariate analysis of variance of
participants’ self-reported confidence and self-reported advocacy in job seeking also showed
significant differences with participants in cluster 1 (The Actioners) showing higher scores on
both questions than those in cluster 2 (The Precontemplators) (F[2, 84] = 13.53, p < 0.001).
However, the participants in cluster 1 (The Actioners) did not differ in return-to-work rate (within
6-months of assessment) (53.7%) compared to that of cluster 2 (The Precontemplators) (38.9%)
(Chi-square, p = 0.17).
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J Occup Rehabil (2006) 16:697–705 703

Discussion

This study collected the evidence on the psychometric properties of the Chinese version LASER.
The results obtained from a group of injured Chinese workers who participated in a return-to-
work program suggested that the C-LASER is relevant to reflecting the changes in experiences of
these workers. The subscale scores of the C-LASER are found useful for differentiating workers
at different stages of employment readiness, and their experiences can be represented by at least
two C-LASER profiles. The workers who were identified to have both higher contemplation
and action subscale scores appear to be a distinct group. The other group of workers was
identified as having a higher pre-contemplation subscale score. The “Ready for action” or “The
Actioners” group of workers was found to have significantly higher physical function, less pain
and higher social function than those in the “pre-contemplation” or “The Precontemplaters”
group. The former group also had higher confidence and self advocacy in job seeking. Although
the ready–for-action group has a higher rate in return-to-work, it was not statistically significant.
The test structure of the original LASER had three distinct factors [6, 10]. This is different
from what was revealed in this study, which groups the items into only two distinct factors. The
first factor seems to combine the items which were originally grouped under the contemplation
and action subscales. The second factor includes items which were under the pre-contemplation
subscale. The differences in the test structures between the Chinese and original versions of
LASER can be explained in two ways: the concept of readiness among Chinese workers, and
differences in participants’ characteristics between the present and previous studies.
The most significant findings are the combined contemplation and action stages of injured
workers. This could be attributable to the high value which Chinese workers place on working,
and the existing workers’ compensation and social security system in Hong Kong. The combina-
tion of the contemplation and action stages suggests that the participants appeared to realize the
need to return-to-work but had not taken any action to engage in job seeking. This is supported
by a study conducted by Westwood and Lok [11] which showed that unemployed workers in
Hong Kong had a strong tendency to seek employment. Their initiatives and engagement in
job seeking were regarded as being under the action phase of stage-of-change. The incentives
gained from engaging in work were largely from the income generated and the immediate sense
of success. Westwood and Lok also demonstrated that workers in Beijing shared these charac-
teristics. Other studies have suggested that the termination of benefits gained from a workers’
compensation system was related to workers’ returning to work after injury [12]. In other words,
injured workers were more likely to take action on job seeking, and hence return to work, when
the workers’ compensation benefits ran out [13].
Most of the participants in this study had undergone a medical assessment of which the
results concluded the workers’ compensation process. The participants in Group 1 cluster had
a relatively higher return-to-work rate than those in Group 2. The participants in the Group 1
cluster were those who had higher scores on the “contemplation and action” subscales, which
suggests that these participants tended to consider ways and engaged more in job seeking and
return-to-work activities. The design of this study did not enable us to further differentiate to what
extent the strong work ethics of Chinese workers might have influenced the C-LASER subscales
scores and their return-to-work after injury. Further study should focus on differentiating the
effects of workers’ culture and workers’ compensation systems on modulating their behavior
with regard to returning-to-work.
In this study, the results revealed that a high “precontemplation” subscale score is associated
with lower physical and social functioning, higher pain intensity, and lower confidence and self
advocacy in job seeking. These characteristics have previously been reported to be important
for lowering the readiness to return-to-work. For instance, patients with traumatic brain injuries
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704 J Occup Rehabil (2006) 16:697–705

and the unemployed tended to have more anxiety and depressive symptoms [14], and a higher
intensity of pain, which affects subjects’ emotional distress [15]. The results obtained in this
study therefore are consistent with those reported in previous studies.
It is, however, surprising to find that the human capital factors, such as educational level, were
not associated with the “pre-contemplation” versus “contemplation and action” effects. Previous
studies have suggested that workers who were younger and with a higher educational level had
a better chance of returning to work. The majority of the participants in this study were middle-
aged and their educational levels comparable. The restricted age range could have lowered the
power of the analysis. As far as the educational level factor is concerned, the participants in
the combined “contemplation and action” group appeared to have a higher level of educational
level (40.7% versus 30.6% for the 10 years or above group) than the “pre-contemplation”
group. However, due to the comparatively small group size (n = 54 and n = 36), this factor
did not reach a statistically significant level. Based on the results of this study, human capital
factors seemed to have no effect on subjects’ readiness to return to work. Therefore, stages of
employment readiness, together with subjects’ perceived physical and social functioning and
pain intensity, seemed to be the salient factors in determining the return-to-work rate of injured
workers. A further confirmatory study should, however, increase the sample size in order to
increase the power of the analysis.
The internal consistency of the combined “contemplation and action” subscale yielded a
satisfactory ICC index. In contrast, the internal consistency of the pre-contemplation subscale
was rather low (ICC = 0.69). This indicates that the consistency associated with the items in
the pre-contemplation stage was low. As mentioned before, the concept of “action-oriented” was
as perceived by subjects may have contributed as subjects tended to show a higher consistency
on contemplation and action items, than on pre-contemplation items. The test-retest reliability
of 11 items was satisfactory. There were three items: 7, 10 and 12, which were under the pre-
contemplation subscale and had relatively low ICC indexes. From our experience, the participants
appeared to be “positive” and “motivated”. This could be attributable to the fact that Chinese
are conscious of “self-respect” and “saving face”. These behaviors would be less consistent,
thus resulting in lower test and retest reliability and relatively low internal consistency of the
pre-contemplation stage. Further studies should focus on illustrating item statements to improve
cultural relevance and further explore work readiness among Chinese subjects.

Conclusion

The C-LASER is a useful instrument for distinguishing stages of readiness to work among
injured workers. Further studies are warranted to improve cultural relevance of items and further
exploration of perception on work readiness by Chinese counterparts. Cultural characteristics
of Chinese clients also warrant further attention in developing effective treatments to match the
specific needs of Chinese rehabilitation clients. Finally, the utility of the C-LASER with clients
in different special populations could be explored (e.g., clients with psychiatric disabilities) to
further establishing generalizability of the instrument in vocational rehabilitation.

Acknowledgments The authors thank The Hong Kong Workers’ Health Centre for the joint collaboration of this
study, Mr. K.L. Leung, Mr. Patrick So, Mr. Frank Lai, Mr. Johnathan Chow, Mr. Ken Chung and Mr. Eric Fung
for contributing their time and effort in the expert panel review, Mr. Yanwen Xu and Mr. Jiaqi Li for their effort
on data collection. We would also like to thank all the participants of this project. This study would not have been
possible without their support.
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 J Occup Rehabil (2006) 16:697–705 705

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