Work productivity of people with a psychiatric disability working in social firms

Abstract

BACKGROUND:

Several factors impact work productivity in employees with a psychiatric condition.

OBJECTIVE:

In the context of social firms (SFs) the goal of this study is to test a theoretical model to predict work productivity across time, while considering worker and workplace factors.

METHODS:

222 people with a psychiatric disability employed in SFs were enrolled in a longitudinal study (6 month follow up) and completed the baseline battery of questionnaires on health (severity of symptoms), individual (self-esteem as a worker) and organizational factors (organizational constraints and supervisory support), and their work productivity (also measured at follow-up). Path analysis was used to test the hypothetical model, assessing individual and organizational factors in the context of social firms that could facilitate or hamper work productivity in the immediate term (T1), as well as the stability of work productivity in the middle/long term (T2 or 6 month follow up).

RESULTS:

Work productivity of people with a psychiatric disability was affected negatively by severity of the symptoms, organizational constraints, and positively by self- esteem as a worker at T1. The stability of work productivity was significant across time (T2). Supervisor support was only related to work productivity at 6 month follow-up.

CONCLUSIONS:

The results highlight the importance of the supportive workplaces for people with mental disorders that SFs provide, and the stability of work productivity across time. Supervisor support seems to have a delayed impact on work productivity. In future studies, researchers could determine how individual and organizational variables influence job tenure of employees with a psychiatric disability.

Keywords

Health individual and organizational factors job tenure supervisor

1 Introduction

The economic burden of mental illness in Canada is estimated to be $51 billion dollars annually [1]. A large proportion of the burden is related to work loss. Mental disorders are among the most important causes of absenteeism at work [2, 3]; representing an annual wage-based productivity impact of $6.3 billion dollars [4]. Work integration can be difficult for people with a psychiatric disability, such as schizophrenia, bipolar and depressive disorders [5]. Even though the majority of people with a psychiatric condition can, and would like to work, between 70% and 90% do not [6]. Evidence indicates that the high job turnover and poor work productivity is not due to symptoms alone but to other individual and organizational issues that are beginning to be understood. For example, job tenure in the competitive job market averages about 8 months [7]. In contrast, job tenure is much longer for people working in Social Firms (SFs)—between two [8] and six years [9]. Moreover, SFs are businesses that require a competitive level of productivity, indeed SFs promote the idea to help people with a psychiatric condition or other types of disability to improve their ability to work [10]. However, systematic research is needed to understand the individual and organizational factors that can affect the work productivity of people with mental disorder, and if the work productivity is stable across time. The SF context has been understudied and could eventually provide relevant information for stakeholders in the regular labor market, who search to hire this population [7].

Like businesses in the competitive sector, SFs offer a living wage (minimum wage or more) but also aim to promote the physical, social, and mental health of their employees, often in settings with high proportions of individuals with psychiatric and/or physical disabilities [10 –12]. SFs seek to produce goods and/or services, while creating innovative solutions to exclusion and unemployment for potentially marginalized groups [13]. Considering their social mission and the fact they receive subsidies from the government, SFs have positive impacts on both the output (e.g., goods and services) and the social outcome (social integration of individuals with a disability) [14]. SFs provide support from immediate supervisors who are literate in mental health, and, as such, do not hold stigmatizing attitudes toward people with a psychiatric condition [15]. Furthermore, SFs “have the potential to create workplaces that enable people to realize their productive potential” [16, p. 866]. Yet, little is known regarding the productivity of SF workers with a psychiatric condition. Because of SFs’ specific social, environmental and economic impacts, work productivity of SF employees with a psychiatric disability should be assessed in a comprehensive way, i.e. looking into health, individual and environmental factors [16]. Indeed, work productivity is a central outcome for the organizations and the workers, particularly linked to job tenure. Job tenure of people with a severe mental disorder in the competitive labor market is in general short, but it seems longer in the organizational environment of social firms. Moreover, social firms appear to be a promising, though understudied, employment alternative for people with a psychiatric condition [15 , 17–19]. Therefore, assessing the individual and organizational factors in the context of social firms that can facilitate or hamper work productivity in the short as well as in the middle/long term, can provide useful information about how to intervene on the work productivity of workers with a mental disability.

1.1 Severity of clinical symptoms and work productivity

It is widely agreed that psychiatric conditions are associated with decreased work productivity, and decreased ability to work [20]. A vast body of literature supports the relationship between work outcomes (e.g., work productivity, work functioning) and psychiatric symptoms. Studies on depression and work productivity, for example, consider depressive symptoms as strong determinants of work productivity [21, 22]. Even symptoms of mild severity are documented as affecting work productivity [21] in terms of presenteeism, and absenteeism [23]. In fact, several studies have concluded that the symptomatology of a psychiatric condition is a strong predictor of employment outcomes [24, 25], with effects on work productivity [24]. Yet, symptoms tend to exacerbate with work stress [26] and it is unclear how a supportive work environment, such as is found in SFs, can help mitigate the effects of psychiatric symptoms and facilitate the work productivity of people with a psychiatric condition.

1.2 Self-esteem as a worker and work productivity

Corbière et al. [27] indicated that people with a psychiatric condition who obtained a competitive job, showed a significant improvement in their self-esteem as a worker. Worker’s self-esteem can promote effective work functioning and work productivity. Indeed, positive work outcomes (e.g., work performance, work productivity) are influenced by the person’s general self-esteem through their work self-esteem [28]. In other words, even if both concepts are interrelated, general self-esteem can be assessed in different contexts, whereas work self-esteem is contingent on a specific domain, the workplace in particular. As such, one’s self-esteem as a worker is linked to one’s performance or work productivity [29]. In the context of SFs, self-esteem as a worker could significantly increase given SFs’ mission to promote a collaborative management of workers while focusing on autonomy and self-empowerment [30, 31]. Thus, it is expected that self-esteem as a worker could become a lever for work productivity in employees working in SFs.

1.3 Organizational constraints and work productivity

Growing evidence suggests that work-related factors and organizational constraints (e.g., work overload) highly affect work productivity [32]. To illustrate this, Jaskiewicz and Tulenko [33] describe how the productivity of community health workers, for instance, is determined in large part by their workload, supplies and equipment. Gilboa, Shirom, Fried, and Cooper [34] showed that specific organizational stressors are most strongly negatively related to performance—role ambiguity (e.g., unclearly defined tasks) being the most detrimental. However, only few studies explored the impact of organizational constraints in workers with mental disabilities in SFs work environment (e.g., [35]). According to Chell [36], SFs achieve a precarious balance between focusing on their social mission for people with a disability and their need to be self-sufficient without depending on public sector subsidies. Too much emphasis on the profit maximisation could impact organisational constraints and as a consequence, workers’ productivity.

1.4 Supervisor support and work productivity

Good work relationships can also improve workforce productivity, as social support is a positive determinant of effort, and a lever for individual performances [33, 37]. In this vein, when workers with a psychiatric condition receive support and constructive feedback from their immediate supervisor in the regular labor market, their job tenure is significantly longer [38]. Inversely, decreased productivity has been associated with decreased supervisory support and poor supervisor relationship [39 –41]. In contrast, in SFs, the emphasis is on improving interpersonal and personal skills in employees [15], and supervisors are therefore trained to improve their workers’ interpersonal skills, self- esteem, and in turn, work productivity.

In view of the preceding, the aim of this study is to test a model on individual and organizational aspects affecting work productivity of people with mental disorders working inside SFs, in the immediate (cross-sectional perspective) and after 6 months (longitudinal perspective). Based on the literature, we will test a hypothetical model on individual aspects (i.e., severity of the symptoms and worker’s self-esteem), and organizational aspects (i.e., organizational constrains and supervisor support) affecting, positively or negatively (see Fig. 1), work productivity of people with mental disorders employed inside SFs, in the immediate (cross-sectional perspective (T1)) and after 6 months (longitudinal perspective (T2)). Specifically, we hypothesize that the different individual and organizational aspects will have a daily effect on the work productivity of people with mental disability (T1), and we expect that work productivity will be stable over time (T2). An in-depth analysis of the individual and organizational factors affecting work productivity of employees with a psychiatric condition adds to the knowledge of the timing associated with the effects of factors. This knowledge can be used to understand how to improve the work integration and job tenure of people with a mental disability.

Fig.1

Theoretical model. T1 = baseline, T2 = 6-month follow-up.

2 Method

2.1 Design and participants

This study is part of a larger study examining the work integration of people with a psychiatric condition employed in SFs in the Canadian provinces of Ontario (greater Toronto area) and Quebec (greater Montreal area). The study consists of three main objectives: 1) to describe social firms in terms of work accommodations implemented, availability and usefulness for people with a mental disorder working in this type of organizational structure [70], 2) to identify the salient predictors of work productivity (the present paper), and 3) to examine healthcare service use and costs for social enterprise workers versus a population of people with psychiatric disorders who are currently unemployed and seeking employment [71]. The protocol for this study was reviewed by the by the University of Sherbrooke’s and the Centre for Addiction and Mental Health’s Research Ethics Boards. Informed consent was obtained from all study participants by trained study staff (Quebec and Ontario).

Data were collected prospectively (baseline and 6-month follow-up) from workers with a psychiatric condition working in Ontario SFs (n = 80) and Quebec SFs (n = 142). The worker sample (n = 222) primarily consisted of males (58%), with an average age of 46 (SD = 9.9 years), and who were single and never married (64.9%). Most of the participants (87%) did not have a college degree. The majority of the sample reported having a diagnosis of schizophrenia (42%). Other diagnoses included mood disorders (31.4%), anxiety disorders (15.6%), others (i.e., substance abuse or personality disorders; 11%). With respect to job tenure in their SFs, participants reported working an average of 75 months (SD = 67.7). Workers from the two Canadian provinces did not differ in gender, age, and job tenure, except for psychiatric diagnosis (x² = 13.27, df = 1, p = 0.001), with 51.4% (n = 73) of the workers from Quebec with a schizophrenia spectrum diagnosis compared to 26.3% (n = 21) in Ontario. Province, gender, diagnosis, age and job tenure were included in the model as a covariates (i.e., control variables).

2.2 Measures

All the scales used in this study were validated in French and English with people with a psychiatric condition. Moreover, the scales have acceptable psychometric qualities (e.g., all alpha coefficients >0.79).

The short version (18 items) of the Brief symptom Inventory (BSI; [42, 43]) was used to assess the severity of symptoms. Different symptoms were measured: somatization, obsessive-compulsive, sensibility, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Items were rated on a 4 point rating scale from 1 (“not at all”) to 5 (“extremely”). For this study, a global severity index was calculated, with an internal consistency (Cronbach’s alpha) of α= 0.89.

The Rosenberg Self-Esteem as a Worker Scale (RSEWS; [27]) is a 10-item questionnaire that measures worker’s self-esteem. It is an adaptation of the Rosenberg self-esteem scale [44] to the context of a worker. The items are measured on a 4-point Likert scale from 1 (Strongly Disagree) to 4 (Strongly Agree). The RSEWS contains an equal number of positively (e.g., “As a worker, I feel that I am a person with worth, at least on an equal basis with other workers”) and negatively (e.g., “As a worker, I wish I could have more respect for myself”) worded items. For this study, a self-esteem as a worker general score was used, with an internal consistency of α= 0.83.

The 11 items of the Organizational Constraints Scale (OCS; [45]) were used to calculate a global score representing the interference of situations or things with work task performance (e.g., “Poor equipment or supplies?”, “Inadequate help from others?”). All items were scored on a 5-point scale, ranging from 1 (“less than once per month or never”) to 5 (“several times per day”). The internal consistency of the organizational constraints global score for this study is α= 0.88.

For the assessment of the supervisor support the Karasek JCQ/supervisor support dimension was used [46, 47]. The 6 items used (e.g., “My supervisor pays attention to what I am saying”; “My supervisor is successful in getting the job done”) are scored on a 5-point scale ranging from 1 (not at all) to 5 (fully). The internal consistency of the supervisor dimension in this study is α= 0.79.

To assess work productivity for people with mental disorders we used the Endicott Productivity Scale, a self-report measure (EWPS; [48]). The scale consists of 25 items on a 5-point Likert scale (from 0 = never to 4 = almost always). The scale covers four productivity areas: attendance (absenteeism and time on task), quality of work, performance capacity, and personal factors (social, mental, physical, and emotional). For this study we used a reverse-total score from 0 (worst possible score) to 100 (best possible score), in which high scores represent a high level of accomplishment of working duties and tasks. The coefficient alpha for this study is 0.90 for T1 (baseline) and T2 (6 month follow-up).

2.3 Data analyses

Path analysis was performed using LISREL 8.7 [49], in order to test the theorized model. Prior to conducting the path analysis, we performed a preliminary analysis of the data in order to verify whether the data were appropriate for use in a path analysis [50]. In the analyses, asymptotic covariance matrix along with the sample covariance matrix was used, and the parameters were estimated by the Robust Maximum Likelihood (RML). Assessment of the fit was based on several indices: Chi-square Test, Comparative Fit Index (CFI; [51, 52]), Non-Normed Fit Index (NNFI; [52, 53]), and Root Mean Square Error of Approximation (RMSEA; [54]). A satisfactory fit is obtained when the chi-square test is non- significant [55, 56]. RMSEA index values less than 0.05 indicate a good fit, values up to 0.08 reasonable fit, ones between 0.08 and 0.10 indicate mediocre fit, those greater than 0.10 indicate poor fit [57]. The CFI and NNFI indicate acceptable model fit if they equal or exceed 0.90. Hu and Bentler [56] suggest more stringent criteria, only accepting a model when the RMSEA is less than 0.06, and when the NNFI and the CFI are equal to or greater than 0.95. After inspecting the model fit indices, individual parameter estimates and explained variance (R²) were considered.

3 Results

Table 1 reports the correlations between study variables. All correlations were in the hypothesized directions. Figure 2 shows the finding for the path analysis model, standardized parameter estimates are presented for ease of interpretation. The model showed good fit indices: χ² = (55, N = 222) = 24.50, p = 0.99; RMSEA = 0.0; NNFI = 1.00; CFI = 0.99. The control variables (i.e. Canadian province, gender, age, diagnosis and job tenure in SF) included in the model tested were not significant (critical ratio/t-value <1.96). All the paths, except the one between supervisor support and work productivity at baseline, were significant and followed the hypothesized direction. As expected, work productivity of SF workers with a psychiatric condition is mostly stable overtime (work productivity at baseline was significantly related to work productivity at 6 months); work productivity at T1 is negatively affected by the severity of symptoms as well as organizational constraints, and positively affected by self-esteem as a worker. The relation of supervisor support and work productivity at baseline was not significant, but the relationship was significant at 6 months. The final adjusted model is presented in (Fig. 3) (fit indices: χ² = (55, N = 222) = 15.58, p = 1.00; RMSEA = 0.0; NNFI = 1.00; CFI = 0.99). The explained variance of the final model tested was: R² = 0.35 for work productivity at baseline, and R² = 0.20 for work productivity at 6 months. Since supervisor support significantly predicted work productivity at six months (T2), we conducted additional analyses to test other potential independent variables as predictors, and thus adding paths between variables at T1 (i.e., severity of the symptoms, worker’s self-esteem, organizational constrains) and work productivity at T2. Except for supervisor support and work productivity at T1, none of the other paths were significant (critical ratio/t-value <1.96: severity of the symptoms = – 0.31, worker’s self-esteem = 1.00, organizational constrains = – 0.90), indicating that only the work productivity at T1 and supervisory support at T1 predicted work productivity at T2.

Fig.2

Model tested. T1 = baseline, T2 = 6-month follow-up, NS = non-significant.

Fig.3

Model adjusted. T1 = baseline, T2 = 6-month follow-up, NS = non-significant.

Table 1

Means, Standard Deviations, and Correlations among Study Variables

	M	SD	1	2	3	4	5	6	7	8	9	10	11
1. Province (1 = Ontario)	–	–	–
2. Gender (1 = female)	–	–	–0.09	–
3. Diagnosis (1 = schizophrenia)	–	–	_0.24 ^c	0.14^a	–
4. Age	46.16	9.86	0.07	–0.03	0.07	–
5. Job tenure	75.07	67.67	–0.04	0.04	–0.13^a	0.32^b	–
6. Severity of symptoms	3.09	0.55	0.04	0.03	0.14^a	–0.01	0.07	(0.89)
7. Self-esteem as a worker	3.14	0.50	0.01	0.00	–0.03	0.07	–0.15^a	–0.34^c	(0.83)
8. Organizational constraints	1.63	0.70	–0.08	0.10	0.06	–0.26^c	0.07	_0.29 ^c	–0.09	(0.88)
9. Supervisor support	3.35	0.49	0.01	0.04	–0.01	0.07	–0.11	–0.13^a	_0.26 ^c	–0.20^b	(0.79)
10. Work productivity T1	0.76	0.50	0.09	–0.02	–0.07	0.14^a	–0.07	–0.51^c	_0.30 ^c	–0.40^c	0.15^a	(0.90)
11. Work productivity T2	0.81	0.50	0.02	–0.06	–0.09	0.20^b	–0.13	–0.26^c	_0.23 ^c	–0.26^c	_0.24 ^c	_0.41 ^c	(0.90)

Note: N = 222. Cronbach’s alpha in brackets on the diagonal. ^ap < 0.05; ^bp < 0.01; ^cp < 0.001.

4 Discussion

To successfully integrate people with mental disorders in the workplace, we need to better understand factors that lead to work productivity, given its link to job tenure. Supported employment programs are currently the only evidence-based practice to help people with a psychiatric condition obtain competitive employment. However, job tenure of people with psychiatric conditions in the competitive labor market is often brief. In contrast, SFs tend to report longer job tenure and therefore offer valuable contexts in which to examine the work productivity of workers with mental disorders [15 , 58–60]. Furthermore, contemporary research (e.g., [61]) has moved beyond a single-factor model (i.e., individual characteristics) in understanding the employment of people with psychiatric disabilities, favoring a more complex model of interactions involving several factors (including environmental aspects). As such, the goal of this study was to contribute to the understanding the contributions of health, individual and organizational factors to predicting work productivity in SFs. Consistent with the literature [21 , 33], our results confirm that health (i.e., severity of clinical symptoms), individual (i.e., self-esteem as a worker) and workplace factors (i.e., organizational constraints) predict work productivity in SFs.

As for health variables, in their meta-analysis of predictors of employment outcomes (including work productivity) for people with a severe mental illness such as bipolar disorders, Tse, Chan, Ng, & Yatham [25] mentioned that the effect size for symptom severity varied from small to moderate (0.16 in absolute value), demonstrating the more severe the symptoms, the poorer the work productivity. In our study this coefficient was higher (0.38 in absolute value), probably due to the fact that most of our study’s participants had a severe mental illness and had struggled in the competitive labor market.

With respect to worker’s self-esteem, this variable was a modest but significant predictor of work productivity. In their meta-analysis, Bowling et al. [28] showed that the organization-based self-esteem (i.e., employees’ beliefs about their own values and competencies as organizational members) yielded a corrected correlation of 0.34 with work performance; a similar coefficient to our study (0.26). Our results also corroborate Krupa et al.’s study [62] suggesting that SFs provide workers with psychiatric conditions opportunities to work in a commercial venture (as opposed to a rehabilitative program), and to acquire work experience and self-confidence.

Regarding organizational variables, our results indicate that organizational constraints predict work productivity, but less than severity of symptoms. In contrast, Merrill et al.’s study [32] looking into predicting work productivity loss, conducted with close to 20,000 workers (without a mental illness diagnosed), found that organizational constraints (e.g., too much to do, too little time) were the strongest predictors, above and beyond individual characteristics and health. In our study, because of the nature of the sample, the organizational constraints are secondary to explaining work productivity. However, to promote work productivity for people with a severe mental illness, it is also important to adapt work environments to accommodate the needs of employees across a continuum of symptom severity [21]. In this vein, work accommodations often implemented in SFs could compensate for health problems or medication side-effects [38], and thus provide a balanced and enabling work environment, in which people with a severe mental illness can evolve [33].

As in Merrill’s study [32], the cross-sectional part of our design did not indicate that current supervisor support was a significant predictor of current work productivity. However, the fit of the adjusted model improves when current supervisory support is used to predict work productivity in the long-run (6 months after). It appears that supervisor support affects work productivity, but primarily over time. Possible explanations related to this finding includes: 1) there is a cumulative effect of supervisory support over time, or a delayed effect, 2) the worker and the supervisor get to know each other better in a medium/long period of time, and the support is adjusted to be better tailored to the worker’s needs, or 3) other potential variables involved in the relation between supervisory support and work productivity could explain this result (e.g., mediators such as work accommodations). These results suggest that the supervisor plays a critical role in work productivity and the effects of the supervisor contributions are more clearly seen over the long term. They support suggestions that to improve work productivity in employees with a psychiatric condition, supervisors require time to work with employees to support them in overcoming obstacles to their productivity [40].

In their qualitative study conducted in social firms implemented in France, De Pierrefeu et al. [63] showed that immediate supervisors support workers in overcoming potential obstacles regarding their work by different means, namely by teaching how to work independently, manage emotions and perceive new challenges. This training can result in increased worker confidence and self-esteem, which is translated into increased work productivity, as suggested by results of our study. De Pierrefeu et al. [63] identified more than 155 supervisors’ competencies working in social firms, all together representing nine conceptual categories (e.g., ensure tailored assistance for each worker, be a help reference for the worker, show hope in the worker). The results of their qualitative study support our result suggesting a delayed effect of supervisory support. This information could be useful, not only for key actors in organizations, such as immediate supervisors working in SFs but also, those involved in the competitive labor market.

The present study has some limitations. First, the study was conducted in a specific organizational context, i.e. social firms, which were developed to employ people with a psychiatric and/or physical disability. Consequently, it is difficult to generalize the study’s results to other settings. Nonetheless, most of our results were comparable or similar to those of other studies conducted with employees with or without a disability and in a variety of workplaces around the world. Second, work productivity was assessed via self- report. It would have been interesting to also obtain the supervisor’s assessment of work productivity. The Endicott work productivity measure was appropriate in the context of our study since it assesses the impact of illness on productivity at work, and most of the tools for work productivity are self-report measures [64 –67]. Third, the absence of cognitive variables, such as executive functions, in the theoretical model is a shortcoming since the meta-analysis of Tse et al. [25] highlighted the importance of considering cognitive deficits (verbal memory, executive functions) when predicting employment outcomes (e.g., work productivity). Considering a large proportion of SF workers with schizophrenia are more likely to have cognitive deficits, including these variables in future studies would not only help to better understand their impact on work productivity, but also how the work environment can compensate for such deficits. Indeed, there is evidence that supported employment programs that are enhanced by providing training for cognitive functioning can be more effective than those that do not provide it [68]. Fourth, in our theoretical model, we did not include self-esteem in general but we have instead chosen to evaluate a specific type of self-esteem, related to the organizational context. As Bowling et al. [28] emphasized, this type of self-esteem is likely to be more precise and more stable across time for workers having longer work experiences. In future studies, it would be of interest to evaluate the self- esteem as a worker when they begin working at an SF as well as over time to learn more about how self- esteem changes during employments and its eventual impact on work outcomes. Fifth, a comparison between worker productivity in firms in the competitive labor market versus social firms as well as its predictors of work productivity in the two contexts would be of interest. As Suijkerbuijk et al. [7] concluded in their Cochrane review on diverse vocational rehabilitation programs (e.g., supported employment programs, social firms) dedicated to people with a psychiatric condition, trials on the effectiveness of social enterprises and other vocational programs are lacking. Yet, these interventions are widely used across the world. Therefore, such trials are warranted, particularly for comparing work productivity and job tenure across types of employment programs and firms. Sixth, to better understand the influence of the supportive behavior at T1 on work productivity evaluated at T2, it would have been interesting to measure if specific supportive supervisor behaviors took place between T1 and T2 in order to disentangle this relationship.

In conclusion, growing evidence suggests that work-related factors and organizational constraints can affect productivity [32 , 69]. A vast body of literature reports that psychiatric symptomatology is a strong predictor of work productivity [25]. More recently, work-specific self-esteem is of interest, particularly for people with a disability and who have been unemployed for a long period of time. In the particular context of SFs, in which people with a psychiatric disability are employees, our results confirm that health, individual and organizational variables influence work productivity over time. These findings suggest that SFs have similarities with organizations in the competitive labor market since the same factors have an impact on work productivity. Implicitly, this suggests that entrepreneurship in SFs can be similar to organizations in the competitive labor market [36]. More studies are warranted to better understand not only how workers’ self-esteem and supervisory support interact overtime and their mutual influence on work productivity, but also how the type of entrepreneurship in SFs can influence the implementation of work accommodations to facilitate work productivity of employees with a psychiatric condition. Furthermore, these avenues of research could determine if the variables mentioned above can influence job tenure, a crucial issue for people with a psychiatric disability.

Conflict of interest

None to report.

Footnotes

Acknowledgments

We would like to acknowledge the contribution of the participants and the social enterprises for kindly taking part in this study. This research was supported by a grant from the Canadian Institutes of Health Research (#245479).

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