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.
||Impact on Employment
|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)
|Jang et al. 2005
Conroy and McKenna 1999
Lin et al. 2009
Norweg et al. 2011
Ramakrishnan et al. 2011
Tsai et al. 2014
Hwang et al. 2015
||Having access to general assistive technology services
Ability to use a computer shortens the time to employment post-SCI.
Kruse et al. 1996
||Job search assistance, job placement assistance, on-the-job support and training, and maintenance services are associated with successful employment outcomes
|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
|McNeal et al. 1999
Chapin and Kewman 2001
Schonherr et al., 2004
||Social support favours employment
Being married favours employment
Exception: Franceschini 2012 (403)
|Burns et al. 2010
Jang et al. 2005
Pflaum et al. 2006
Huang et al. 2017
||Higher socioeconomic status of surrounding area is positively associated with employment; suburban areas were associated with a better employment rate compared with urban areas
|Area of Residence
||Rural residence is associated with lower return to work
||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)
||Ferdiana et al. 2014
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.
||Impact on Employment
||Decrease in government benefits deter individuals with SCI from returning to work.
|Chan and Man 2005
Hedrick et al. 2006
Jongbloed et al. 2007
Pflaum et al. 2006
||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)
|Wehman et al. 2000
Engel et al.1998
Ottomanelli et al. 2011 (social security disability benefit)
Paul et al. 2013
||Being insured by Medicaid (US) was associated with reduced training and lower employment rates
||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.
|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.
||Krause and Anson 1996
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.