Work and Employment

Environmental Factors

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.

The influence of environmental factors associated with employment post-SCI is based on observational studies with level 5 evidence, and are summarized in tables 4 and 5.

Table 4. Environmental Facilitators Influencing Employment Post SCI

Environmental Factors	Impact on Employment	Study N	Study reference
Ability to use transportation independently	Those with the ability to independently use transportation are more likely to be employed/return to work. Driving a modified vehicle is associated with increased odds of being employed. Exception: Chan and Man 2005 (16)	196 167 403 219 3726 84 2986 461	Jang et al. 2005 Conroy and McKenna 1999 Franceschini 2012 Lin et al. 2009 Norweg et al. 2011 Ramakrishnan et al. 2011 Tsai et al. 2014 Hwang et al. 2015
Assistive technology	Having access to general assistive technology services Ability to use a computer shortens the time to employment post-SCI.	3514 391	Arango-Lasprilla 2011 Kruse et al. 1996
Vocational rehabilitation	Job search assistance, job placement assistance, on-the-job support and training, and maintenance services are associated with successful employment outcomes	3514	Arango-Lasprilla 2011
Job accommodations and adaptations	Identification of appropriate necessary accommodations alleviates work-related problems and facilitates employment Work modifications including job adaptations and decreased work hours are associated with return to work	46 12 57	McNeal et al. 1999 Chapin and Kewman 2001 Schonherr et al., 2004
Social Support	Social support favours employment Being married favours employment Exception: Franceschini 2012 (403)	83 11424 1013 196 20143 353	Burns et al. 2010 Arango-Lasprilla 2009* Botticello 2012 Jang et al. 2005 Pflaum et al. 2006 Huang et al. 2017
Surrounding Area	Higher socioeconomic status of surrounding area is positively associated with employment; suburban areas were associated with a better employment rate compared with urban areas	1013	Botticello 2012
Area of Residence	Rural residence is associated with lower return to work	120	Kader et al. 2018
Nature of Occupation	Higher odds of return to work is associated with: high/middle level occupation based on the Dutch Standard Classification of Occupations (NSS) low physical intensity of pre-injury occupation (NSS)	114	Ferdiana et al. 2014

Discussion

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 & 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.

Table 5. Environmental Barriers Influencing Employment Post SCI

Environmental Factors	Impact on Employment	Study (N)	Study reference
Financial disincentives	Decrease in government benefits deter individuals with SCI from returning to work.	16 191 357 143	Chan and Man 2005 Hedrick et al. 2006 Jongbloed et al. 2007 Pflaum et al. 2006
Financial incentives	Those who are entitled to compensation are less likely to be engaged in the labour force. Ottomanelli et al. 2011 (238) (receiving social security benefits was a disincentive for employment but receiving Veterans disability benefits is not) Those with no fault compensation had lower income and lower return to work (29-39% vs. 42-54% but no significant difference)	109 3514 83 403 238 118	Wehman et al. 2000 Arango-Lasprilla 2011 Engel et al.1998 Franceschini 2012 Ottomanelli et al. 2011 (social security disability benefit) Paul et al. 2013
Health insurance	Being insured by Medicaid (US) was associated with reduced training and lower employment rates	111	Phillips et al. 2012
`Disability` discrimination (negative attitudes towards those with disabilities)	Companies tend to discriminate against individuals with SCI by offering interviews less frequently when a SCI was disclosed. Negative employer attitudes Perceived discrimination was associated with current unemployment.	2228 83 167	Ravaud et al. 1992 Engel et al. 1998 Conroy and McKenna 1999
Inaccessibility of the workplace	Physical inaccessibility is a reason for not returning to work.	231	Krause and Anson 1996

Discussion

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 & 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.

Conclusion

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.

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