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Personal Factors Associated with Employment Post-SCI

Several personal characteristics have been identified as factors which may interfere with the ability to return to the labor market (Anderson et al. 2007; Lidal et al. 2007, Ottomanelli and Lind 2009). Some of these characteristics cannot be modified (e.g. level of injury) while others such as level of education, health status, and work skills can be modified with appropriate and targeted interventions. Tables 2 and 3 identify the non-modifiable personal factors and the modifiable personal and activity/participation factors, respectively, which influence employment after SCI. All of these studies are Level 5 evidence.

Table 2: Non-Modifiable Personal Factors Influencing Employment after SCI

Personal factorsImpact on employmentStudy (N)Study reference
Sex 

Being male tends to favour return to work.

 

Exceptions:

Anderson and Vogel 2002 (195), Arango-Lasprilla et al. 2009* (11424), Arango-Lasprilla et al. 2010*(11090), Gunduz et al. 2010 (152),

Krause and Reed 2011* (781), Ottomanelli et al. 2011 (238)

195

3756

259

615

1397

165

559

5925

82

234

181

2986

183

247

Anderson and Vogel 2002

Krause et al. 1999

Krause 2003

Krause and Terza, 2006

Krause 2010c*

Lidal 2009

Marti et al. 2012

Meade et al. 2004

Pell et al 1997

Tomassen et al. 2000

Rowell and Connelly 2010

Tsai et al. 2014

Ullah et al. 2015

Clark et al. 2017

EthnicityBeing Caucasian tends to favour return to work

 

Exception:

Ottomanelli et al. 2011 (238)

 

 

195

11424

11090

3514

1177

1032

3756

615

1362

1134

1397

14454

781

5925

111

118

247

Anderson and Vogel 2002

Arango-Lasprilla 2009*

Arango-Lasprilla 2010*

Arango-Lasprilla 2011

Hess et al. 2000

Krause et al. 1998

Krause et al. 1999*

Krause and Terza 2006

Krause and Reed 2009*

Krause et al 2010b*

Krause 2010c*

Krause et al 2010d*

Krause and Reed 2011*

Meade et al, 2004

Phillips et al. 2012

Paul et al. 2013

Clark et al. 2017

AgeEmployment tends to increase with age up to 30 and remain the same up to middle 40’s

 

 

 

 

 

 

Employment is lower in individuals aged 55-64 compared to those aged 45-54

195

167

20143

234

181

 

 

353

 

620

149

1323

1159

Anderson and Vogel 2002

Conroy and McKenna 1999

Pflaum et al. 2006

Tomassen et al. 2000

Rowell and Connelly 2010 (labor market participation may

w/ age)

Huang et al. 2017

 

Hirsh et al. 2009

Blauwet et al. 2013

Jetha et al. 2014

Marti et al. 2018

Age at time of injuryYounger age at injury tends to increase employment167

1177

1032

3756

84

2986

Conroy et McKenna 1999

Hess et al. 2000

Krause et al. 1998

Krause et al., 1999*

Ramakrishnan et al. 2011

Tsai et al. 2014

Duration of injuryThe rate of employment increases with duration of injury (20-30167

20143

2986

353

Conroy and McKenna 1999

Pflaum et al. 2006

Tsai et al. 2014

Huang et al. 2017

Severity of injury

(cervical or tetraplegia)

 

 

 

Higher and more severe injury (i.e., tetraplegia and complete injury) has a negative influence on employment

 

People experiencing fewer functional limitations have a higher likelihood of obtaining employment

 

Exception:

Botticello 2012 (1013),

Gunduz 2010 (152),

Marti et al. 2012 (559),

Phillips et al. 2012 (111),

Ottomanelli et al. 2011 (238)

195

11424

11090

114

167

403

1177

1032

259

1362

1398

1134

781

165

219

91

2986

353

120

Anderson and Vogel 2002

Arango-Lasprilla 2009*

Arango-Lasprilla 2010*

Castle 1994

Conroy and McKenna 1999

Franceschini 2012

Hess et al. 2000

Krause et al. 1998

Krause 2003

Krause and Reed 2009*

Krause et al. 2010*

Krause et al. 2010b*

Krause and Reed 2011*

Lidal 2009

Murphy et al. 1997

Wang et al. 2002

Tsai et al. 2014

Huang et al. 2017

Kader et al. 2018

Education pre-injury

 

Higher education pre-injury is a key factor in employment. People with tertiary education prior to injury were up to 8 times more likely to be in employment post-SCI.

 

Exception:

Ottomanelli et al. 2011 (238)

11424

3514

1013

114

169

403

152

60

259

615

1362

1398

1134

1397

781

1329

219

559

219

234

Arango-Lasprilla 2009*

Arango-Lasprilla 2011

Botticello 2012

Castle 1994

Conroy and McKenna 1999

Franceschini 2012

Gunduz 2010

Hilton et al. 2017

Krause 2003

Krause and Terza 2006

Krause and Reed 2009*

Krause et al. 2010*

Krause et al. 2010b*

Krause 2010c*

Krause and Reed 2011*

Krause et al. 2012*

Lin et al. 2009

Marti et al. 2012

Murphy et al. 1997

Tomassen et al. 2000

Pre-injury workPositive influence on employment:

– Being employed at injury

– Returning to pre-injury job

– Lower physical demands of job pre-injury

 

11424

167

3756

259

1398

1134

192

72

20143

61

234

192

60

114

183

Arango-Lasprilla 2009*

Conroy and McKenna 1999

Krause et al. 1999*

Krause 2003

Krause et al. 2010*

Krause et al. 2010b*

Kurtaran et al. 2009

Murphy et al. 2009

Pflaum et al. 2006

Ramakrishnan et al. 2011b

Tomassen et al. 2000

Young et al. 2004

Young et al. 2011

Ferdiana et al. 2014

Ullah et al. 2015

Pre-injury chronic conditionsNegatively impacts post-injury employment219Lin et al. 2009
Felony convictionsNegatively impacts ability to find employment regardless of vocation rehabilitation program157LePage et al. 2014
* These studies are based on data from the National Spinal Cord Injury Statistical Center (NSCISC) in the United States. In general, two different types of analyses are undertaken (1) retrospective analysis of data in the database (2) a cross-sectional survey that is sent out to individuals identified from the database. Given that the same eligibility criteria are often used for studies relating to work and employment, it is likely that the data from the same individuals are being used for multiple studies.

 

 

Discussion

Several personal characteristics cannot be modified but must be taken into consideration in the assessment of potential (re-)employment after SCI as summarized in table 2. These factors can be divided into 4 categories: 1) demographics, 2) time-related, 3) injury-related and 4) work/education factors. The evidence of the influence of these factors (level 5) is based on observational studies. Being Caucasian is a demographic factor that favors employment. Male gender has been a strong demographic predictor of employment, but a number of recent studies have shown no significant difference between males and females. However, 3 of the 6 studies showing no significant difference come from the same data source. The interaction between age, age at injury and the duration of injury is very complex making it difficult to determine their individual influence on employment. While the proportion of employed people tends to increase with age (increases up to about 30 years of age and is maintained up to 40 years), younger age at injury and longer duration of injury (up to 20 years post-injury) are better predictors of being employed than age alone. Due to a non-linear effect of age on labor market participation, it is likely that work participation may decrease with increasing age at some point after 40. Hirsch et al. (2009) reports that individuals aged 45-54 were significantly more likely to be employed than those aged 55-64. A more severe injury tends to decrease the probability of employment. A higher level of education seems to be a factor in increasing the probability of employment. Factors related to pre-injury work such as being employed at injury, returning to pre-injury job or holding a job requiring a lower physical intensity tend to positively influence employment.

Conclusions

There is level 5 evidence (see Table 2) that being male, Caucasian, and younger at time of injury; having a longer duration of injury, higher education pre-injury; and having a low-intensity pre-injury job are non-modifiable personal factors that positively influence employment opportunities after SCI.

There is level 5 evidence (Hirsch et al. 2009) that the severity of injury is a non-modifiable personal factor that negatively influences employment opportunities after SCI.

Non-modifiable personal characteristics such as being male and Caucasian, younger at injury, with a longer duration of injury (20-30 years), with higher pre-injury education, being less severely injured, and being employed at injury in a low-intensity job increase the likelihood of employment post-SCI.

Table 3: Modifiable Personal/Activity and Participation Factors Influencing Employment after SCI

PersonalImpact on employmentStudy (N)Study reference
Education / training post-injury

 

 

 

 

 

 

 

Positive influence on employment:

–       higher level of education (high school or above)

–       vocational retraining

–       attaining post-secondary education

114

167

152

169

259

1362

1398

1329

192

559

5925

459

20143

234

118

181

60

1323

176

353

Castle 1994

Conroy and McKenna 1999

Gunduz 2010

Jang et al. 2005

Krause 2003

Krause and Reed 2009*

Krause et al. 2010*

Krause et al 2012*

Kurtaran et al. 2009

Marti et al. 2012

Meade et al. 2004

Murphy et al. 2003

Pflaum et al. 2006

Tomassen et al. 2000

van Velzen et al. 2009

Rowell and Connelly 2010

Hilton et al. 2017

Jetha et al. 2014

Ferdiana et al. 2014

Huang et al. 2017

Household incomeHigher household income group had higher vocational satisfaction. The lower income group had greater improvements in vocational satisfaction over the course of the 10-year study.434Cao et al. 2014
Secondary health conditionsIn 10 papers, secondary health conditions are a barrier to employment (e.g., medical complications, bowel incontinence, urinary tract infection, chronic pain, depression, pressure ulcer)

 

Exception:

Hirsch et al. 2009 (N=620; pain, fatigue, sleep)

Krause et al. 2011 (N=781; health status)

Meade et al. 2011 (N=5925; secondary health conditions)

Matthew et al. 2013 (N=108; pressure ulcers)

Ramakrishnan et al. 2011 (N=84; medical co-morbidities.)

 

 

195

1013

781

 

403

559

103

234

83

219

2986

 

Anderson and Vogel 2002

Botticello et al. 2012

Hirsch et al. 2009 (psych functioning)

Franceschini 2012

Marti et al. 2012 (pain)

Mann et al. 2013 (pain)

Wehman et al. 2000

Burns et al. 2010 (depression)

Lin et al. 2009 (depression)

Tsai et al. 2014 (catheter indwelling in bladder, pain)

 

 

 

Functional independenceFunctional independence increases the likelihood of being employed

 

 

 

 

 

 

 

Independence in bladder emptying is positively associated with return to work

 

 

Physical function was the most important  in relation to return to work in patients with SCI

195

1013

14620

169

72

109

 

234

2986

 

192

2986

 

 

167

Anderson and Vogel 2002

Botticello et al. 2012

Cohen et al. 2012

Jang et al. 2005

Murphy et al. 2009*

Ramakrishnan et al. 2011 (personal care)

Tomssen et al. 2000

Tsai et al. 2014

 

Kurtaran et al. 2009

Tsai et al. 2014

 

 

Jeong et al. 2015

Psychological component

(locus of control, values placed on work, expectations)

 

Positive influence on employment:

–       endorsement of gender norms

–       internal locus of control

–       valuing work

–       positive expectations toward work

–       positive attributional style (the individual’s propensity to “internalize” positive employment outcomes to his/her own attributes, capabilities or functioning

–       personal sense of motivation

–       family and rehabilitation professionals serving as extrinsic motivators

–       social participation is correlated with wellbeing, decreased anxiety and depression

–       subjective wellbeing

–       hope and sense of direction

–       gaining self confidence

–       self-efficacy and secure attachment

83

459

57

109

181

60

30

60

13

44

190

4

84

Burns et al. 2010

Murphy et al. 2003

Schonherr et al. 2004

Wehman et al. 2000

Rowell and Connelly 2010

Murphy et al. 2011

Boyle et al. 2014

Hilton et al. 2017

Ramakrishnan et al. 2016

Reed et al. 2016

Umucu et al. 2016

Willbanks et al. 2015

Blake et al. 2017

Relationship statusPositive influence on employment

–       participants in a relationship at the time of injury were 3.5 times more likely to be employed at 2 years post discharge

–       married participants

60

461

1323

Hilton et al. 2017

Hwang et al. 2015
Jetha et al. 2014

Social RolesParticipating in more social roles had a positive influence on employment for young/middle aged, and older adults1323Jetha et al. 2014
Wheelchair skillsPeople with better wheelchair skills are more likely to return to work.

 

Manual wheelchair users have higher employment rates than power wheelchair users

118

 

 

30

2986

van Velzen et al. 2009

 

 

Hastings et al. 2011

Tsai et al. 2014

 

Activity / participation factorImpact on employmentStudy (N)Study reference
Sport participationParticipation in organized sports was associated with increased likelihood of employment.149Blauwet et al. 2013**
Social ParticipationDecreased social participation reduces the odds of being employed3162Tsai et al. 2017
* These studies are based on data from the National Spinal Cord Injury Statistical Center (NSCISC) in the United States. Generally speaking, two different types of analyses are undertaken (1) retrospective analysis of data in the database (2) a cross-sectional survey that is sent out to individuals identified from the database. Given that the same eligibility criteria are often used for studies relating to work and employment, it is likely that the data from the same individuals are being used for multiple studies.

**The definition of employment varies among different studies. These studies consider full-time students to be unemployed while others include students within the definition of employment.

 

Discussion

Several factors can be modified in the post-injury period to prevent deleterious effects or to increase the likelihood of employment after SCI. These factors are categorized as: 1) education / training, 2) health status, 3) functional independence, 4) psychological issues, 5) wheelchair skills and 6) participation. Secondary health conditions such as pain, depression, spasticity, pressure ulcers, severe urinary tract infections and respiratory problems are likely to limit employment opportunities but this finding should be considered in conjunction with the severity of injury. For example having tetraplegia leads to a higher occurrence of secondary health complications due to larger extent of affectation than paraplegia. The level of education or pursuit of training after SCI remains a key factor that can offset other factors such as the severity of injury. Specifically, a professional degree and work that is not physically demanding increases the likelihood of employment. Some psychological attributes such as an internal locus of control, positive values and expectations regarding work including internalization of positive work outcomes are likely to favor employment.Participation in organized sports may facilitate employment through the building of mentorship/relationships, socialization and self-confidence (Blauwet et al. 2013). Reducing environmental barriers may enhance social participation and facilitate employment status.

Conclusion

There is level 5 evidence (see Table 3) that being married, having education post-injury, having fewer secondary health conditions and higher functional independence, having better work related values and a higher internal locus of control, and better wheelchair skills are modifiable personal factors that positively influence employment opportunities after SCI.

Modifiable personal characteristics such as being highly educated post-SCI, limiting the occurrence of health complications, having a higher level of independence (including wheelchair skills), and having the trait of valuing work can increase the likelihood of employment post-SCI.