Auswahl der wissenschaftlichen Literatur zum Thema „Return to work“

Philosophiae Doctor - PhD
Background: Stroke is acknowledged globally and among Nigerian rehabilitation researchers as a public health problem that leave half of its survivors with significant neurological deficits. The attendant sequelae of stroke affects the functional ability, limits activity performance and participation of stroke survivors within the community. The inability to re-establish pre-existing roles after stroke further poses additional challenges on the society, friends and families of the stroke survivor with regards to cost and burden of care. Although stroke disrupt the career pathway of working age survivors briefly, recurrently or permanently; a systematic pathway that facilitates job placement and retention at work for stroke survivors could reduce the devastation and burden caused by unemployment following stroke. As this vocational rehabilitation pathway and programme is currently unavailable for stroke survivors, this study aimed to design a RTW intervention programme that could facilitate the work re-entry for stroke survivors in the state of Osun, Nigeria. Method: The study utilized a multi-phase mixed method research design that was guided by the Intervention Mapping (IM) framework to achieve its objectives. This consisted of three iterative phases that informed one another with the findings culminating into the developed return to work programme for stroke survivors in Osun State. Phase one used a convergent mixed method parallel approach to obtain baseline information on the RTW process, the impairments, activity limitation, and the participation restrictions experienced by stroke survivors in Osun state, Nigeria in two distinct stages that involved a cross-sectional survey and qualitative interviews. The cross sectional survey administered questionnaires that included the Work Rehabilitation Questionnaire, the International Classification of Functioning, Disability and Health (ICF) Brief Core Sets for vocational rehabilitation (VR) and the Work Impact Questionnaire (WIQ) using the face to face method. Descriptive statistics such as measure of central tendencies and frequencies as well as inferential statistics such as logistic regression analysis were performed on the questionnaire data. The qualitative study involved concept mapping using in-depth interviews with stroke survivors who have and those that have not RTW. The transcripts from the in-depth interviews were analysed using the thematic content method. Phase two entailed a scoping review of literature that reported on interventions aimed at facilitating RTW of stroke survivors. The last phase of the study involved a Delphi study with experts in the field of stroke and vocational rehabilitation. The Delphi survey was conducted over three rounds with the final draft of the RTW programme emerging at the third round. Results: Two hundred and ten stroke survivors with mean age 52.90±7.92 responded to the quantitative stage of the phase thereby yielding a response rate of 76.36%. Sixty three point eight percent of the respondents had returned to work with half of them in full time employment (32.9%) while 36.2% had not returned to work. The majority of the respondents identified that travel to and from work (43.8%) and access at work (43.3%) had an impact ranging from ‘quite a bit’ to ‘extreme’ on their ability to work on the WIQ. The results from the quantitative stage further showed that more than ten percent of the respondents experienced complete problem in four components of activity and participation domains of the ICF brief core sets for VR and these include remunerative employment (21.4%), acquiring new skills (17.1%), non-remunerative employment (16.7%), as well as acquiring, keeping and terminating jobs (14.3%). Similarly, energy and drive functions (41.9%) and higher level cognitive function (36.2%) were indicated as culminating in moderate to severe problems in more than a third of the respondents while the “performance of complex interpersonal relationship” and “exercise tolerance function” resulted in no or little difficulty for the respondents. The findings from the logistic regression analysis showed that the combination of side of body affected by stroke (left), type of vocational rehabilitation programme, symptoms of stroke, environment, body function impairments as well as activity and participation problems were the factors that predict RTW after stroke. The logistic regression model significantly explained 55.0% to 75.4% of the variance in RTW after stroke and correctly classified 89.0% of all the cases/respondents. Results from the qualitative stage of the first phase suggests the lived experience of returning to work after stroke to have entailed three themes that was represented by a concept map. The first theme revealed that “it was difficult to live with stroke” for the survivor. The second theme revealed that the stroke survivors’ environment could either worsen or lessen the difficulty experience while the third theme highlighted the various issues that directly impacted on the resumption of worker role of the participants. The scoping review phase (phase two) identified that RTW interventions for stroke survivors falls into three core components which includes 1) intervention components that interface with the stroke survivor; 2) intervention components that interfaced with the workplace and; 3) components that describe strategies of implementation. These core components are interventions that could guarantee an effective RTW for strokes survivors when included in a RTW programme. In the third phase which was the concluding phase of the study, 13 experts in the field of stroke and vocational rehabilitation unanimously agreed at the third round of Delphi that the content of RTW programme for stroke survivors should include an assessment phase, work intervention training phase, work test placement phase and clients full participation in worker role phase that will span a 12 week duration. The developed RTW programme, conceptualized as Stroke Return to Work Intervention Programme (SReTWIP) was designed to be individually tailored to meet the need of the stroke survivor and implemented by an interdisciplinary team that will include the OT and PT as key members. Equally, the stroke survivor is expected to be involved in the decision making process throughout the duration of the SReTWIP. And finally, the programme is to be coordinated by a case manager who will be a member of the interdisciplinary team. Conclusion: It can be concluded that 63.9% of stroke survivors in Osun State, Nigeria return to work. Problems pertaining to lack of energy and drive functioning; higher level cognitive functioning; acquiring new skills; handling stress and psychosocial demands; travel to and from work and access were the common body impairments and problems with activities and participation restrictions that the stroke survivors encountered. Similarly, the study concludes that a multi-faceted programme, the SReTWIP, comprising of four interconnected phases of interventions that targets multiple factors such as personal and environment factors influencing work resumption is likely to be more effective in facilitating quick RTW after stroke.

The overall aim of this thesis was to gain new knowledge of factors and interventions that improve work ability and return to work (RTW) among women on long-term sick leave from human service organizations (HSOs). The specific aims of the studies were: to evaluate the associations between the self-rated Work Ability Index (WAI) and Work Ability Score (WAS), and the relationship with prospective sick leave, symptoms, and health (Paper I); to investigate whether intervention with myofeedback training or intensive muscular strength training could decrease pain and increase work ability among women with neck pain (Paper II); to examine the associations between workplace rehabilitation and the combination of supportive conditions at work with work ability and RTW over time (Paper III); and to explore experiences, views, and strategies in the rehabilitation process for RTW (Paper IV). This thesis is based on a prospective cohort study (n=324) and a randomized controlled study (RCT) (n=60, participants with neck pain). Both quantitative and qualitative methods were used. The data collection consisted of questionnaires, laboratory-observed data, register-based data, and interviews. The results showed a very strong association between WAI and WAS, and results predicted future sick leave degree, health-related quality of life, vitality, neck pain, self-rated general health, self-rated mental health, behavioral stress, and current stress (Paper I). In the RCT (Paper II), individuals in the myofeedback intervention group increased their vitality and work ability over time and individuals in the intensive musculoskeletal strength training group increased their WAI, WAS, and mental health over time. WAI, WAS, and RTW increased over time among individuals provided with workplace rehabilitation and supportive conditions at work (Paper III) such as a sense of feeling welcome back at work, influence at work, possibilities for development, degree of freedom at work, meaning of work, quality of leadership, social support, sense of community, and work satisfaction. Women described (Paper IV) how they were striving to work and how they had different views, strategies, and approaches in the rehabilitation process for RTW. They expressed a desire to work, their goals for work, and their wishes for work. In the rehabilitation process for RTW they described their interaction with stakeholders as either controlling the interaction or struggling in the interaction. They described strategies to cope with RTW in terms of yo-yo (fluctuating) working: yo-yo working as a strategy or yo-yo working as a consequence. This thesis identifies factors of importance in improving work ability and RTW among women on long-term sick leave from HSOs. For women with neck pain, the intervention study showed feasibility of the intervention and demonstrated improved work ability and decreased pain (Paper II). The intensive muscular strength training program, which is easy for the individual to learn and perform at home, was associated with increased work ability. The results regarding rehabilitation highlight the importance of integrating workplace rehabilitation with supportive conditions at work to increase work ability and improve RTW (Paper III). Women expressed that they were striving to work and that they wanted to work (Paper IV). These women were “going in and out” of work participation (yo-yo working) as a way to handle the rehabilitation process. For assessing the status and progress of work ability among women on long-term sick leave, the single-question WAS may be used as a compliment to the full WAI as a simple indicator (Paper I).

Akademisk avhandling som för avläggande av medicine doktorsexamen vid Sahlgrenska akademin, Göteborgs universitet, kommer att offentligen försvaras i hörsal Hamberger, Medicinaregatan 16 A, Göteborg, måndagen den 6 oktober 2014, klockan 09.00

Introduktion: Sjukfrånvaron i Sverige är hög och kunskap om vad som påverkar återgång i arbete efter sjukskrivning behöver utvecklas. I processen kring återgång i arbete är bedömning av arbetsförmåga en viktig del. Bristen på valida, reliabla och teoretiskt förankrade bedömningsinstrument inom området är dock ett bekymmer eftersom tillförlitliga bedömningar av arbetsförmåga är en förutsättning för utformning och genomförande av interventioner för att stödja återgång i arbete. Denna typ av interventioner kräver multidisciplinär kompetens där arbetsterapeuter utgör en viktig funktion. Vid bedömning av arbetsförmåga bör personens subjektiva uppfattning om sin situation beaktas, då den har betydelse för utfallet av återgång i arbete. Worker Role Interview (WRI) och Work Environment Impact Scale (WEIS) är två arbetsrelaterade intervjuinstrument, som har utvecklats i syfte att bedöma subjektiva psykosociala och miljömässiga faktorers påverkan på arbetsförmåga. Den teoretiska grunden till WRI och WEIS är Model of Human Occupation, som är en modell med fokus på aktivitetsutförande i relation till psykosociala faktorer. Inledande prövningar av WRI och WEIS reliabilitet och validitet har genomförts. Bedömningsinstrumenten har bearbetats och översatts till svenska och används främst av arbetsterapeuter, som arbetar med personer med arbetsrelaterad problematik. Syfte: Det övergripande syftet med avhandlingen är att undersöka användbarheten av bedömningsinstrumenten Worker Role Interview och Work Environment Impact Scale för identifiering av psykosociala och miljömässiga rehabiliteringsbehov av betydelse för återgång i arbete. Metod: Avhandlingen består av fem empiriska studier. I samtliga studier har erhållen information bearbetats kvantitativt. I studie IV har även kvalitativ bearbetning genomförts. Studie I, II och IV är tvärsnittsstudier och studie II och V är två års longitudinella studier. I studie I samlades information in via enkät. I studie II, III och V bestod den huvudsakliga informationen av skattningar utifrån WRI variabler och i studie IV var bedömningar utifrån WEIS i form av skattningar och nedskrivna kommentarer till skattningarna den huvudsakliga informationen. Resultat: I studie I undersöktes vilka teoretiska utgångspunkter och professionsspecifika modeller arbetsterapeuter i Sverige ansåg påverka den psykiatriska vården och den psykiatriska arbetsterapin. Det psykosociala perspektivet var den teoretiska utgångspunkt som hade störst påverkan både på psykiatrisk vård och på psykiatrisk arbetsterapi. Den arbetsterapeutiska modell som flest identifierade var Model of Human Occupation. Detta resultat indikerar att Model of Human Occupation verkar vara användbar inom arbetsterapi och motiverade vidare användning av modellen i denna avhandling. Det som dock också framkom i studie I var att arbetsterapeuter inom psykiatrisk vård använde professionsspecifika modeller i en relativt liten utsträckning. Ett sätt att öka tillämpningen av teori i praktik är att använda teoretiskt grundade bedömningsinstrument. I studie II, III, IV och V har endera av de Model of Human Occupation- baserade bedömningsinstrumenten WRI och WEIS använts och värderats. I studie II och V prövades WRI:s förmåga att predicera återgång i arbete efter långvarig sjukskrivning. Det område i WRI som uppvisade bäst prediktivitet var området ”Självuppfattning” vars variabler beaktar personens motivation för återgång i arbete i form av personens upplevelse av kompetens och effektivitet för att utföra arbetsuppgifter och hantera utmaningar i arbetet. De två WRI variabler som bäst kunde predicera vilka som skulle återgå respektive inte återgå i arbete vid uppföljning efter två år var: ”Tro på sin arbetsförmåga”, och ”Dagliga vanor och rutiner”. Resultaten tyder på att kunskap om hur tro på den egna förmågan stärks och kunskap om dagliga vanor och rutiners påverkan på utförande av arbete är central vid genomförande av interventioner i syfte att stödja personer att återgå till arbete efter sjukskrivning. I studie III prövades WRI:s konstrukturella validitet i en internationell studie. Samtliga variabler i WRI, förutom de som tillhör miljöområdet, uppvisade en god konstrukturell validitet dvs mätte psykosociala faktorers påverkan på arbetsförmågan. WRI:s skattningsskala verkar stabil och valid mellan olika länder och för personer med olika diagnoser. I analysen framkom att WRI kunde särskilja mellan personers psykosociala arbetsförmåga på tre olika nivåer. I studie IV undersöktes hur personer med erfarenhet av långtidssjukskrivning uppfattar att faktorer i arbetsmiljön stödjer respektive hindrar personens utförande av arbete och välbefinnande genom bedömningar utifrån WEIS. De faktorer som uppfattades som mest stödjande var olika former av sociala interaktioner på arbetet samt uppfattningen om arbetets värde och mening. De faktorer som uppfattades som mest hindrande var olika krav i relation till arbetsgenomförandet samt den belöning som erhålls för arbetet. Konklusion: Sammanfattningsvis så kan WRI användas för bedömning av psykosociala faktorers påverkan på arbetsförmågan. I WRI ingår variabler som kan predicera återgång till arbete upp till två år efter genomförd bedömning. WEIS verkar användbart för att identifiera arbetsmiljöfaktorer som stödjer respektive hindrar personers välbefinnande och utförande av arbete. Att komplettera olika datainsamlingsmetoder är en förutsättning för att uppnå en så god bedömning av arbetsförmåga som möjligt. Den information som WRI- och WEISintervjuer genererar är värdefull, då den kan utgöra en viktig grund för planering av individspecifika rehabiliteringsinsatser. Bedömningsinstrumenten WRI och WEIS med sin teoretiska förankring i Model of Human Occupation kan anses vara användbara för att identifiera psykosociala och miljömässiga rehabiliteringsbehov i syfte att stödja personer i processen åter till arbete efter sjukskrivning.
Introduction: In Swedish society the sick-leave rate is high and a better understanding is required of the factors that facilitate return to work. In the return to work process, assessments of peoples’ work ability play an important role. However, the lack of usable, valid, reliable, and theoretically sound assessment instruments for assessing work ability is a concern. Credible and theoretically sound assessment methods for assessing clients’ work ability strengthen the possibilities for making valid interpretations and obtaining important information for composing further intervention strategies which can guide suitable interventions in the process of returning to work. Such interventions need multi-professional expertise. In this area occupational therapists can offer valuable contribution. In the overall assessment of work ability the unique individual’s subjective perception of the situation needs to be considered since this has been found greatly relevant for return to work. The Worker Role Interview (WRI) and the Work Environment Impact Scale (WEIS) are two work-related interview assessment instruments that have been developed to assess subjective psychosocial and environmental factors of work ability. The WRI and the WEIS have been primarily tested for reliability and validity and are theoretically founded in the Model of Human Occupation (MOHO), which is an occupation-focused model addressing psychosocial factors. They have been adapted and translated to Swedish and are used among Swedish occupational therapists working with clients experiencing work-related problems. Aim: The overall aim of this thesis was to evaluate the usefulness of the assessment instruments the Worker Role Interview and the Work Environment Impact Scale for identifying psychosocial and environmental rehabilitation needs essential for returning to work. Methods: Five empirical studies were performed, all of which were analysed quantitatively, with the exception of study IV in which both qualitative and quantitative analysing methods were used. Studies I, III and IV were cross-sectional while studies II and V were two-year longitudinal studies. In study I, data were collected by a questionnaire, in studies II, III and V the primary data constituted of ratings on the WRI items. In study IV the primary data were ratings of the WEIS items and the written notes beside the rating on each item. Results: In study I, theoretical approaches and professional models that influenced psychiatric care and psychiatric occupational therapy practice among occupational therapists in Sweden was investigated. The most common approach in psychiatric care was the psychosocial approach, and the practice model which was most often used was the Model of Human Occupation. The results indicated that the psychosocial approach and the Model of Human Occupation seemed applicable in occupational therapy, motivating further use of that model. However, it was also found that occupational therapists in psychiatric care used professional practice models to a rather low extent. One way to enhance the application of theory into practice is the use of theory- based assessment instruments. Consequently, the Model of Human Occupation- based assessment instruments, the WRI and the WEIS, have been evaluated and used in the other studies in the present thesis The value of the WRI for predicting return to work after long term sick-leave was investigated in studies II and V. The content area in the WRI with best overall predictive validity for return to work was ‘Personal causation’. Its items focus on the individual’s motivation for return to work in relation to the individual’s feeling of competence and effectiveness in doing work tasks and facing challenges at work. The two WRI items which best predicted whether the participants would be in the working or the non-working groups at the two-year follow up were ‘Expectations of job success’, which concerns beliefs in personal abilities in relation to returning to work, and the item ‘Daily routines’ which concerns the individual’s routines and organisation of time outside work. These results suggest that knowledge about how to strengthen the person’s belief in his or her abilities, how routines impact occupational performance, and how to support the individual in structuring his or her daily doings are needed in interventions aiming at supporting the individual to return to work. In study III the construct validity of the WRI was investigated in an international study. All the WRI items except those related to the environment area seemed to capture the intended construct of the WRI, namely psychosocial ability for return to work. The construct of the WRI seems to be stable and valid across different countries and populations, and the WRI showed an ability to separate clients into three distinct levels of psychosocial ability for return to work. In study IV the impact of the work environment was investigated by using the WEIS among people with experiences of sick-leave. Social interactions at work and the meaning of the work had the most supportive impact and different work demands and the rewards received for the work were perceived as most interfering with work performance, well-being, and satisfaction. Conclusion: The WRI seems to be suitable for estimating psychosocial work ability. In addition it contains items which can predict return to work up to two years after the assessment is conducted. The use of the WEIS revealed supportive and interfering factors for work performance, well-being, and satisfaction among people with experiences of long term sick-leave. The interview format of the WRI and the WEIS seems valuable since it provides comprehensive information which can contribute to the planning of rehabilitation interventions for the unique client. Thus, the WRI and the WEIS, which are theoretically founded in the Model of Human Ocupation are juged to be useful for identifying psychosocial and environmental rehabilitation needs in order to support the individual in returning to work after sick-leave.

The focus of this inquiry is “New Zealand small business employers’ perspectives of the important factors in return-to-work (RTW) of an employee following a musculoskeletal injury or an illness”. Whilst worldwide there is an increasing amount of attention focused on the RTW process in large organisations, there continues to be little understanding of this phenomenon in small businesses. I chose to use a social constructivist theoretical framework drawing on grounded theory methodology to construct some understanding of the employers’ perspectives of the RTW process. Eight small business employers from Auckland and Christchurch participated in this research. Data were gathered using semi-structured interviews. Constant comparative analysis, theoretical sampling and thematic analysis were used to construct two themes from the data. The findings showed that small business employers prefer informal organisational approaches, rely on close working relationships with their staff, are generally wary of bureaucracy and often must run their businesses with limited staff and financial resources. Having an employee off work for a prolonged period of time creates a sizable gap in the staff resources that keep the business running. The employer has responsibility to fill this gap while maintaining a productive business. In the absence of formal injury management practices an ad hoc approach was taken to the RTW process. A number of the employers felt undervalued by key stakeholders, such as doctors, treatment providers, Accident Compensation Corporation and in some cases RTW co-ordinators. Health and safety was a risk all employers appeared to take seriously whereas injury management information and support seemed less of a focus. This research suggests there may be little focus on injury management in small businesses by employers and, that employers perceive greater government emphasis on injury prevention. The extent and associated costs of work disability in small businesses is as yet unknown, but it is likely to be significant. How to support and encourage the uptake of injury management in small businesses in the long term warrants further investigation. Understanding that employers may well lack injury management expertise, experience and resources requires stakeholders to make specific effort with the employer, at the workplace, to facilitate the RTW process.

Work is important. For most, it provides a host of positive emotions as well as the opportunity for social contact and the financial support that enables us to enrich our lives in other ways. If we can no longer work due to ill health, requirement to look after a loved one or following capability or conduct proceedings, the personal impact can be devastating. Even when taking time out of the workplace for positive life enhancing reasons, such as having a baby or a career break to pursue another interest, there can still be a negative impact on knowledge, skills, self-esteem, confidence and finances. An absence of 3 months or more is likely to significantly affect skills and knowledge, and an absence of 2 years or more is generally accepted as a period when formal retraining will be required. Returning to work after a prolonged period away is often greeted with a mixture of eagerness and anxiety for the clinician returning and the manager facilitating the process. For anaesthetists, there are additional concerns compared with some other specialties because anaesthesia requires a comprehensive medical knowledge-base, advanced technical skills to be immediately available and the ability to cope with multiple stimuli as well as the stamina to remain vigilant during long quiet periods. Anaesthesia is an intellectually, physically and emotionally demanding specialty. In this high-risk environment, an underperforming anaesthetist may easily harm a patient. Such high stakes mandate a thoughtful and carefully planned return. Even senior colleagues will require support, supervision, assessment, and in some cases further training. Returning colleagues may have obvious physical scars, but there may also be psychological injuries that are hidden. Good communication is key, but sharing important information must be balanced with confidentiality. If the return is tailored to the individual and managed well, colleagues will come back as healthy, safe and productive doctors. If it is done badly, there is the potential for significant harm to both patients and colleagues.

The COVID 19 pandemic followed by the invasion of Ukraine is a two-punch economic strike never seen in recent history. The pandemic not only disrupted many aspects of a tightly knit integrated world but also exposed its fragility. The devastation of Ukraine and the vast program of sanctions quickly imposed by most major developed countries have accelerated the retreat of globalization. For many decades, Central Bankers and economists considered stable prices as an almost permanent feature. Today, the consumer price index in the US hit a 40-year high at more than 8 per cent and experts were unable to predict such course of inflation. In this paper, we offer a unique perspective on these events. First, we identify a few major influential factors that have altered significantly and reliably inflation since World War II. We then turn to looking at recent events in the light of these factors to try and extrapolate a likely trend for inflation in the coming years. Despite the dire economic challenges of World War II, the economy recovered quickly, the financial imbalances rectified in only a few years and inflation was tamed. Can the same thing be achieved after the pandemic? Our analysis suggests that this is highly improbable. Deep-rooted inflationary forces are at work because of the distortions that the economic order of the last 40 years has created. These distortions, exacerbated by the dual crisis, will take long to repair. We are then looking at an unsettled economic and inflationary future. The wise course of action to avoid a chaotic future requires that the US authorities withdraw from hands-on policies and instead, pave the way for the agile private sector to take the lead and adapt the economy to the changing conditions.

This report shares findings from qualitative research on the impacts of Covid-19 on Cambodian migrant workers in four sites along the Cambodia-Thai border. Government restrictions in Thailand and the border closure in February 2020 led to job losses and reduced working hours, and ultimately to an increase in the rate of return migration. Return migrants were forced to use informal points of entry with the facilitation of informal brokers, facing increased costs and risks and, in the process, becoming undocumented. This report shows an unequal access to health services between documented and undocumented migrants. Even in the context of Covid-19, some migrants continue to travel with young children who support the family, mostly through light agricultural work. URI

We study the medium-term impacts of the Skills for Effective Entrepreneurship Development (SEED) program, an innovative in-residence 3-week mini-MBA program for high school students modeled after western business school curricula and adapted to the Ugandan context. The program featured two separate treatments: the hard skills MBA features a mix of approximately 75% hard skills and 25% soft skills; the soft skills curriculum has the reverse mix. Using data on 4,400 youth from a nationally representative sample in a 3-arm field experiment in Uganda, the 3.5 year follow-up demonstrated that training was effective in improving both hard and soft skills, but only soft skills were directly linked to improvements in self-efficacy, persuasion, and negotiation. Youth in both groups were more likely to start enterprises and more successful in ensuring their businesses’ survival. The program led to significantly larger profits (27.8% and 34.8% for hard and soft treatment arms respectively) and larger business capital investments (72.5% and 58.8% for SEED hard and SEED soft, respectively). Relative to the control group, SEED entrepreneurs created 550 new businesses and 985 additional jobs. The individual’s skill upgrade was rewarded by substantially higher earnings; 38.7% and 21.2% increases in earnings for those who attended hard- and soft-training, respectively, largely generated through self employment. Both SEED curricula were very cost-effective; one (two) month’s worth of extra earnings as a direct consequence of having attended the SEED hard (soft) program would exceed its total cost. 8.5 years post intervention, businesses led by SEED graduates are still more profitable than enterprises owned by the control group. To put these effect sizes into perspective, the control group would need to work 27.2 months and 16.25 months to match the business earnings accrued in a typical year by SEED hard and SEED soft graduates, respectively.

Approximately 300 Americans are estimated to have traveled or attempted to join the Islamic State (ISIS) as part of the group’s campaign in Syria and Iraq between 2013 and 2019. These individuals joined more than 53,000 men, women, and minors from roughly 80 countries. Often referred to as foreign (terrorist) fighters (FTF), these are individuals from third countries who travel to join a terrorist group to support its activities. In the United States (U.S.) context, the FTF designation does not denote the act of fighting itself, but rather the support of a designated foreign terrorist organization (FTO). While many of these radicalized individuals traveled alone to the conflict zone, others brought their families or formed new ones in-theater. As ISIS’ selfdeclared caliphate collapsed, many were killed, some fled to other locations, and many were captured and held by Kurdish forces. Men and some teenage boys were primarily placed in prisons, while women and minors were often moved into detention camps. Today, an estimated 10,000 male FTFs remain held in northeastern Syria including 2,000 men and boys from 60 countries outside Syria and Iraq (third country nationals, or TCNs). In addition, local camps hold close to 55,000 female FTF and FTF-affiliated family members, including roughly 10,000 TCN women and children. Some of these individuals have now been in detention for four years or more. The indefinite detention of FTF and FTF-affiliated families in northeastern Syria is not a tenable solution. In addition to clear humanitarian concerns, there is a significant security risk that the facilities’ inhabitants provide a groundswell of recruits to the still active ISIS campaign in the region. A 2022 U.S. military report puts it bluntly, “These children in the camp are prime targets for ISIS radicalization. The international community must work together to remove these children from this environment by repatriating them to their countries or communities of origin while improving conditions in the camp.” In lockstep, U.S. diplomatic leaders have made repatriation a policy priority empowered by a general domestic partisan consensus that the repatriation of FTF and FTF-affiliated families from northeastern Syria should be done expediently. Progress has been slow, while many Western nations were strongly resistant to bringing their detained citizens home, there is recent evidence for cautious optimism. Approximately 9,200 persons – including 2,700 TCNs and 6,500 Iraqis repatriated since 2019. This year, 13 countries have repatriated roughly 2,300 persons, including more than 350 TCNs. However, more work remains to be done. As of July 15, 2023, 39 U.S. persons have been officially repatriated, including both adults and minors. At least 11 additional U.S. persons have returned on their own accord, ten of whom remained in the U.S. following their return. Furthermore, the U.S. has made the decision to bring several non-U.S. persons to the U.S. to stand trial.