Based on the ICF, the environment includes products and technology (e.g. assistive devices), the natural environment and human-made changes to the environment (e.g. geographic location), support and relationships from others (e.g. support from employer), attitudes (e.g. discrimination due to disability), and services, systems and policies (e.g. healthcare provided) (World Health Organization, 2001). When thinking about the SCI population the most obvious barriers and facilitators are related to the physical environment, particularly for those individuals who have difficulty with mobility. Social, attitudinal, and cultural environment can also been seen to create barriers when one considers the economic disincentives faced, not only by the employers, but also employees with SCI. For instance, the reluctance of an employer to hire an individual with a disability on the belief that they will be less productive or will require costly work accommodations, despite evidence to the contrary is an example of an attitudinal barrier (McFarlin et al. 1991). Moreover the attitudes of other employees can also negatively influence the worksite acceptance of individuals with SCI. In the following section, barriers and facilitators are presented separately. In different contexts a single environmental factor can be perceived to be a barrier and/or a facilitator to employment based on its presence/absence in one’s environment and its impact on effective return to work.
Being an independent driver was positively associated with returning to work post-injury. Reduced dependence on the inflexible, inaccessible, or unreliable options of public transport was likely to be the main reason for this finding (Conroy and McKenna 1999). People with SCI who have computer skills tend to return to work faster after suffering their injury, and to have higher earnings, than otherwise similar workers who lack computer skills (Kruse et al. 1996). Studies specific to persons who experience SCI reported that of those who return to work, the majority were able to do so, in part, because of modifications to the work including job adaptations and decreased work hours. A mentorship or peer support program may also provide a facilitative environment to an individual post-SCI. For example, it was found that those with SCI who completed a mentorship program also improved their functioning, independence, and participation (Shem et al. 2010) which may have contributed to their favorable return to work outcomes. However, it was not clear from the study whether or not participation and successful completion of the mentorship program was directly related to employment post-SCI.
Financial disincentives are gaining support as having a detrimental effect on return to work post-injury. For example, in British Columbia, Canada, social assistance deters recipients from returning to work because once more than $400/month is earned, benefits received while on social assistance such as dental care and prescription medication, are lost (Jongbloed et al. 2007). This also appears to be the case in Australia as the perceived disadvantages of losing social security benefits (which would lead to exclusion from accessing government funded equipment and medical supplies) seemed to deter people from seeking employment post-SCI (Conroy and McKenna 1999). Health insurance benefits which are considered threatened for abolishment or reduction with an increase in work-related income could be a deterrent for people with SCI considering going back to work.
Workplace discrimination can be further classified into ‘disability discrimination’ and ‘racial discrimination’, the latter being addressed in the personal factor section. Disability discrimination is due largely to negative or naïve employer perceptions about the potential productivity of individuals with SCI. Ravaud et al. (1992) found that companies tend to discriminate against individuals with SCI by offering interviews less frequently when the injury was disclosed. Similarly, 80% of Canadians agreed with the statement that “Canadians with disabilities are less likely to be hired for a job than those without disabilities, even if they are equally qualified” (Social Development Canada 2004). Not surprisingly, Jongbloed et al. (2007) found that individuals with SCI viewed the negative attitudes of employers regarding people with disabilities as a barrier to employment. The lack of physical accessibility to the workplace has also been found to hinder return to work.
There is level 5 evidence (see Table 5) that financial disincentives has a negative effect on employment post-SCI but financial incentives has a positive effect on employment except for when receiving social security benefits.
There is level 5 evidence (see Table 5) that health insurance, ‘disability discrimination’ and inaccessibility of the workplace are environmental barriers negatively influencing employment after SCI.
There is level 5 evidence (see Table 4) that ability to use transportation independently, ability to use technological devices, and having access to job accommodations positively influencing employment after SCI.
Environmental facilitators include having access to various assistive devices, using transportation independently, having social support (including being married), and having the possibilities of job accommodation including reduced work hours.
Environmental barriers to employment are social or physical and include financial disincentives, discrimination associated to negative attitudes toward people with disabilities and difficulties with physical access to workplace.
A single environmental factor can be perceived either as a barrier or a facilitator to employment based on its presence/absence in one’s environment and its impact on effective returning to work.