The Arab minority of East Jerusalem: An exploratory study of vocational rehabilitation in mental health

Abstract

BACKGROUND:

The Arab population of East Jerusalem with serious mental illness (SMI) is an ethnic and health status minority that has unique employment issues. Vocational rehabilitation offered to this population is guided by standard regulations that are grounded in knowledge obtained from Western communities on the employment enablers, while negligible research was done to investigate relevance of these enablers for the Arab population.

OBJECTIVE:

The study aims to examine the previously well-established association between motor, cognitive, and emotional personal factors, occupation features, environmental characteristics, and vocational outcomes of job satisfaction and performance among the Arab population of East Jerusalem with SMI.

METHODS:

Twenty-three men and women, aged 23–58, from this minority group who had received vocational rehabilitation participated in this cross-sectional study. They completed standard assessments of motor and cognitive skills, self-efficacy, work-environment suitability, and job satisfaction. Employers then rated their level of functioning at work.

RESULTS:

No correlation was found between the outcome measurements and most of the personal factors and environmental characteristics (p > 0.05), except for an association between job satisfaction, work self-efficacy, and work control. No expected differences were found between vocational rehabilitation programs in the variables of interest (p > 0.05).

CONCLUSION:

The disparity from well-established patterns of association between enablers and employment outcomes reveals unique characteristics of the investigated population and suggests the impact cultural issues has on vocational rehabilitation. The findings raise an urgent call for an in-depth investigation of the complex phenomenon of employment in this population to support sustainable employment benefits and recovery journey.

Keywords

Supported employment sustainable employment motor functioning cognition self-efficacy environment satisfaction with job

1 Introduction

The Arab population is the second-largest ethnic group in Israel (21.1%) [1]. The Arab population differs from the Jewish majority in a range of dimensions, such as ethnicity, religion, values, national narrative, language, communication codes, social structure, etc., all of which constitute inherent cultural diversity [2]. The situation is even more complicated since there is diversity within the Arab population itself in Israel. The Arab society in East Jerusalem (15% of the total Arab population in Israel) historically has unique cultural-social-political characteristics that differentiate them from others of the same ethnicity. For example, they are residents, but not citizens of Israel. In everyday life, these differences are clearly reflected in employment situations. This population was found to be at the bottom of the Israeli labor market. The unemployment rate is the highest in this population, and a larger percentage of those who are employed work in unskilled, physical (“blue collar”) jobs or services, actually caring out most of the basic work in Jerusalem [3]. The employment situation for Arabs living in Jerusalem is even more challenging for people with disabilities. The vast majority of the jobs that are available for this population (again, mostly physical jobs) do not fit the needs, values, or talents of some of them. Thus, belonging to both ethnic and health condition minorities increases the barriers to integration into the labor market and reduces the options for obtaining the benefits of working.

Serious mental illness (SMI) is defined as “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities” [4]. SMI commonly refers to a diagnosis of a psychotic disorder, bipolar disorder, and major depression, but can also include anxiety disorders, eating disorders, and personality disorders, if they lead to severe functional impairment [5]. One of the major life activities that is frequently altered by SMI is employment [6 –8]. For example, according to some reports, people with SMI were underrepresented in the labor market until recently [8, 9] and those who work may demonstrate inferior performance [7], while employment is a meaningful role in the community, and it is also an important axis of one’s recovery journey, well-being, and health according to the report of people with SMI [10, 11] and policymakers [12, 13]. It was found that employment provides a range of benefits to people living with SMI, such as financial stability and access to the local community, as well as a sense of meaning, identity, and belonging [6–8 , 10]. In addition, participation in work reduces the hospitalization rate and dependence level [8 , 15] for this population.

People with SMI want to work and there is mounting evidence that they are capable of work [7–9 , 16]. A range of models and services were designed to support employment in this population (supported employment [SE], e.g., individual placement and support [IPS]) with encouraging evidence as to its effectiveness [6–9 , 14]. Still, difficulties are reported with both obtaining a job and/or keeping it [8, 9]. In addition, there is the challenge of integration into a job of a personal choice, which meets individual’s talents, values, and needs in this population. All these factors are enablers for sustainable employment [17]. These findings demonstrate a need for further research in the field of vocational rehabilitation to inform personally tailored service development [7]. Personally tailored services have the potential to support recovery and promote health, otherwise, the services may be a hindering factor, contributing to further discrimination and disparity [18]. Cultural sensitivity was suggested to be an important component of personally tailored services and enablers to obtain optimal outcomes of health services—sustainable and beneficial employment [19, 20]. This is of particular importance in multicultural communities [20].

Israeli society is a multicultural one, with great diversity and multiple challenges in diversity acceptance, which has the potential to affect health [21]. Thus, the concepts of cultural responsiveness and sensitivity are critical in services that intend to support the recovery journey of people with SMI [22]. Today, rehabilitation services for people with SMI in Israel are delivered under the Israeli Community Mental Health Rehabilitation Law. People who were recognized by the Israeli National Insurance Institute with at least 40% of disabilities that stem from SMI are eligible to receive rehabilitation services to support their integration into everyday life in the following areas: housing and accommodation, employment, education, leisure, and family support. The Israeli Rehabilitation Law provides standard uniform guidelines and regulations for the development and delivery of rehabilitation services in each area. These services, which are based mostly on knowledge built from Western society with values of personal independence and autonomy, the importance of performance, achievements, and goal-orientation [22 –24], may be less relevant and useful for Arab society [22 , 25–27]. Patterns of mental health therapeutic services consumption in Israel may imply the differences between the populations. Even though psychological distress is estimated to be higher among the Arab population [28], the percent of those who receive mental health services (medical and psycho-social) from Arab society is much lower than the percent in the Israeli population (12% and 21.1%, respectively) [1, 18].

Barriers to mental health service usage are complex and inter-related, including limited awareness as to the right to treatment, lower literacy about mental illness, little information about mental health services, stigma, and extensive usage of traditional and religion-based approaches to treatment among the Arab population [25]. However, it was found that one of the critical barriers to mental health service usage is a paucity of culturally adapted services for Arab society [25, 26]. Culture has an impact on all aspects of people’s life, including patterns of integration in the workforce; impacts that are even more prominent among people with mental health issues [29]. A few examples of cultural issues among the Arab population within work are norms of communication, pathways for social connectedness, social and gender roles, attitudes toward authority, work ethics with aspiration for productivity and growth, and a place of religion, family, and immediate community within one’s person’s life, all of which have the potential to determine vocational rehabilitation outcomes [27, 29].

There are additional factors than just cultural ones that have the potential to affect vocational rehabilitation, such as personal skills, workplace environment, and institutional context [30]. There is mounting evidence within Western and Jewish Israeli populations with SMI on contribution of personal factors for sustainable employment: cognition, motor skills, and social and emotional abilities [31, 32]. Within the environment, it was found that physical, social, and institutional aspects are important to the ways employees integrate into the workplace, build interaction, and carry out tasks [33].

Despite the importance of employment and its complexity, to the best of our knowledge, there is no research on vocational rehabilitation in SMI in the Arab society in East Jerusalem. Little research evidence limits opportunities for understanding the complex issue of vocational rehabilitation and restricts the development of effective services to meet the needs of this population, thereby reducing its potential to support recovery, mental health, and well-being [23, 34]. Based on the heuristic framework for cultural adaptation of interventions [35], this study aimed to address the first phase of the process—information collection—to provide a base for the unique issues within mental health vocational rehabilitation of the Arab population in East Jerusalem. Thus, the purpose of this study was to explore previously established associations between enablers for employment—motor, cognitive, emotional functions, and environment characteristics—and employment outcomes on the level of functioning at work and job satisfaction. We hypothesized that if there was no unique issues for this population, we would find patterns of association between the enabling factors and the employment outcomes in the Arab population with SMI similar to those of Western and Jewish Israeli populations with SMI.

2 Materials and method

This exploratory study is observational and correlational, with a cross-sectional design. The study was carried out in accord with the Declaration of Helsinki and received ethical approval from the Psychiatric Rehabilitation Department of the Israeli Ministry of Health and the Ethics Committee of Tel Aviv University (approval number: 20181129, date: 29/11/2018).

2.1 Participants

The participants were recruited through a convenience sample from vocational rehabilitation services that were developed to address employment-related needs in those with SMI and were provided for the Arab population of East Jerusalem. Participants from two programs were enrolled in the study: individual placement and support (IPS) and sheltered employment. IPS was provided according to the established principles [36] and all participants were employed in competitive positions. Sheltered employment took place in a factory that was established to meet the needs of people who have had difficulties integrating into the open labor market. These participants were integrated into non-competitive industrial work for the benefit of practicing work skills and personal communication, but with reduced remuneration [37]. The inclusion criteria were: (1) a mental health diagnosis given by a qualified psychiatrist; (2) age range between 18–60; (3) recognition by the Israeli National Insurance Institute as having a disability of more than 40% due to mental health condition; (4) eligibility for rehabilitation services according with the Israeli Community Mental Health Rehabilitation Law, that provided by the Psychiatric Rehabilitation Department of Ministry of Health; and (5) participation in IPS or sheltered employment services. People with a physical, neurological, or developmental disability that affects daily functioning at work, drug abuse, and/or people who have a custodian were excluded from the research. The sample size calculation was done according to recommendations [38] and was based on the correlation coefficient known from a previous study on the association between measures of job performance and cognitive functioning in the Israeli population with SMI [31]. With the significance level of 0.05 and power of 0.7, which was accepted due to the exploratory nature of the study, the sample size was found to be N = 22.

Twenty-three men and women from the Arab society of East Jerusalem participated in the study. The participants were 23–56 (M = 39.70; SD = 9.58) years old, had 6–16 years of education (M = 10.57, SD = 2.67), were diagnosed with schizophrenia (N = 19, 79.2%) or affective disorders (N = 4, 16.7%), received social benefits (40–50% : N = 5, 22.7%; 75% : N = 14, 63.6%; 100% : N = 3, 13.6%), and were being treated pharmacologically (100%). The participants received IPS services and worked in various jobs in the open labor market (N = 17; 73.9%) or worked in shelter employment at a local factory (N = 6, 26.1%). The types of work within IPS services were cleaner, baker, cook, merchandise sorter in the supermarket, laundry worker, and general factory worker. Twenty of the participants received various housing rehabilitation services (87%) in addition to the vocational services. The duration of the remaining in the employment rehabilitation services among study participants ranged from 2 months up to 12 years (M = 46.59, SD = 37.33) and they worked 10–46 hours per week. More than half of the participants reported the existence of meaningful relationships with other people at the workplace and social connections at work in general (only partially overlapping). Most of the participants reported a feeling of occupational balance in their lives. Detailed personal and work-related information is presented in Table 1.

Table 1
Outcome measures by the groups of demographic and work-related variables

WBI JDI

Social skills Cooperation Work habits Quality of work Personal presentation Final score

M/Med Dif η ² M/Med Dif η ² M/Med Dif η ² M/Med Dif η ² M/Med Dif η ² M/Med Dif η ² M/Med Dif η ²

SD/IQR SD/IQR SD/IQR SD/IQR SD/IQR SD/IQR SD/IQR

Gender

Men 28 U = 25 0.00 30 U = 19.5 0.06 26.5 t = 1.4 0.1 24.9 t = 1.3 0.08 29 U = 15 0.06 134.6 t = 1.2 0.08 29.4 t = 0.9 0.04

83.3% 23-31 23.5–32.4 5.5 6 24–33 23 5.8

Women 26 31 31.3 29.7 31 151.3 32.2

16.7% 24–26 31-31 4.7 5 30-31 10.4 5

Occupational balance

Yes 27.5 U = 28 0.02 31 U = 21 0.1 27 t = 0.5 0.01 25 t = 0.9 0.04 30.5 U = 24.5 0.01 137 t = 0.04 0.00 31.3 t = 2.9 0.3

83.3% 22.5–31 25.5–32 5.5 5.8 26.5–33 22 4.8

No 28 25.5 28.5 28 26.5 137.5 23.3

16.7% 25.3–30.8 19.3–31.8 6.6 7 22.5–33.5 27.5 5.1

Social relationships at work – in general

Yes 26 U = 30.5 0.31 30 U = 37 0.09 25.6 t = 1.9 0.41 24.2 t = 1.6 0.35 30 U = 39 0.14 132 t = 1.4 0.31 31.7 t = 2.1 0.4

62.5% 22–30.5 24.5–32 5.2 5.8 24–33 22.6 5.4

No 30 31 30.3 28.4 31 146.3 27

37.5% 26–31 23–33 5.3 5.6 26–35 20.5 5.2

Social relationships at work – meaningful

Yes 28 U = 37.5 0.09 30 U = 44.5 0.02 26.6 t = 0.5 0.12 25.8 t = 0.14 0.32 30 U = 49.5 0.05 136.4 t = 0.58 0.03 30.2 t = 0.36 0.08

58.3% 25–31 24–32 6.4 6.9 24–33 26.2 6.4

No 26 31 28 25.4 31 137.9 29.3

41.7% 23–30.5 24–33 4.6 5 24–33.5 18.4 4.7

Living situation

Alone 24 χ² = 0.94 0.13 31 χ² = 3.1 0.1 24.4 F = 2.4 0.25 22 F = 2.1 0.29 29 χ² = 5.5 0.24 121.7 F = 2 0.24 31 F=0.83 0.04

16.7% 13–24 21–31 8.5 7.5 13–29 38.9 3.4–64

Parents 30 28 25.4 25 29 134 31.3

29.2% 25–31 22.5–31 5.9 6.9 25–31 15.2 4.5–45

Family 28 32.5 34.5 34.5 29 164.5 29

12.5% 26–28 32–33 0.7 0.7 13–29 2.1 4.5–82

Hostel 26.5 30.5 27.6 25.3 29 137.8 28.8

41.7% 23.5–31 24.5–33 4.2 4.4 25–31 19.3 7.3–75

Marital status

Single 28 χ² = 0.06 0.01 30 χ² = 5.2 0.22 26.8 F = 2.4 0.22 25 F = 2.1 0.2 30 χ² = 4.7 0.14 135.4 F = 2 0.19 30.6 F = 0.51 0.05

58.3% 22.5–31 24.8–32 5.7 6.4 22.5–33 24.5 6.1

Married 27 33 33 31.6 35 158.7 30

16.7% 26–27 32–33 2.6 4.9 31–35 10.2 4.2

Divorced 25% 25 25 24.8 23.6 28 128.2 27.6

23–31.5 19.5–31.5 4.9 3.6 25–30 15.1 5.8

Job

Full-time 28 χ² = 0.4 0.25 26 χ² = 4.4 0.49 26 F = 0.66 0.33 25 F = 0.5 0.29 29.5 χ² = 3.5 0.38 129 F = 0.75 0.29 33.6 F = 1 0.37

25% 16.3–30.8 21.8–31 9.9 11 17–33.8 39.5 3.9

30 h/w 25 32 25.7 23.75 26.5 133.2 30

20.8% 20.5–31 30.5–32 1.3 4.3 22.5–31.3 10.1 3

20 h/w 26 27 27.1 25.6 30 136.8 28.2

14.7% 24–31 22–32 5.3 4.6 25–33.5 20 7.2

10 h/w 28 33 31.3 29.3 33 154 29

12.5% 27–28 30–33 2.3 4.2 31–33 10.4 4.6

	WBI	JDI
Gender
Men	28	U = 25	0.00	30	U = 19.5	0.06	26.5	t = 1.4	0.1	24.9	t = 1.3	0.08	29	U = 15	0.06	134.6	t = 1.2	0.08	29.4	t = 0.9	0.04
83.3%	23-31			23.5–32.4			5.5			6			24–33			23			5.8
Women	26			31			31.3			29.7			31			151.3			32.2
16.7%	24–26			31-31			4.7			5			30-31			10.4			5
Occupational balance
Yes	27.5	U = 28	0.02	31	U = 21	0.1	27	t = 0.5	0.01	25	t = 0.9	0.04	30.5	U = 24.5	0.01	137	t = 0.04	0.00	31.3	t = 2.9	0.3
83.3%	22.5–31			25.5–32			5.5			5.8			26.5–33			22			4.8
No	28			25.5			28.5			28			26.5			137.5			23.3
16.7%	25.3–30.8			19.3–31.8			6.6			7			22.5–33.5			27.5			5.1
Social relationships at work – in general
Yes	26	U = 30.5	0.31	30	U = 37	0.09	25.6	t = 1.9	0.41	24.2	t = 1.6	0.35	30	U = 39	0.14	132	t = 1.4	0.31	31.7	t = 2.1	0.4
62.5%	22–30.5			24.5–32			5.2			5.8			24–33			22.6			5.4
No	30			31			30.3			28.4			31			146.3			27
37.5%	26–31			23–33			5.3			5.6			26–35			20.5			5.2
Social relationships at work – meaningful
Yes	28	U = 37.5	0.09	30	U = 44.5	0.02	26.6	t = 0.5	0.12	25.8	t = 0.14	0.32	30	U = 49.5	0.05	136.4	t = 0.58	0.03	30.2	t = 0.36	0.08
58.3%	25–31			24–32			6.4			6.9			24–33			26.2			6.4
No	26			31			28			25.4			31			137.9			29.3
41.7%	23–30.5			24–33			4.6			5			24–33.5			18.4			4.7
Living situation
Alone	24	χ² = 0.94	0.13	31	χ² = 3.1	0.1	24.4	F = 2.4	0.25	22	F = 2.1	0.29	29	χ² = 5.5	0.24	121.7	F = 2	0.24	31	F=0.83	0.04
16.7%	13–24			21–31			8.5			7.5			13–29			38.9			3.4–64
Parents	30			28			25.4			25			29			134			31.3
29.2%	25–31			22.5–31			5.9			6.9			25–31			15.2			4.5–45
Family	28			32.5			34.5			34.5			29			164.5			29
12.5%	26–28			32–33			0.7			0.7			13–29			2.1			4.5–82
Hostel	26.5			30.5			27.6			25.3			29			137.8			28.8
41.7%	23.5–31			24.5–33			4.2			4.4			25–31			19.3			7.3–75
Marital status
Single	28	χ² = 0.06	0.01	30	χ² = 5.2	0.22	26.8	F = 2.4	0.22	25	F = 2.1	0.2	30	χ² = 4.7	0.14	135.4	F = 2	0.19	30.6	F = 0.51	0.05
58.3%	22.5–31			24.8–32			5.7			6.4			22.5–33			24.5			6.1
Married	27			33			33			31.6			35			158.7			30
16.7%	26–27			32–33			2.6			4.9			31–35			10.2			4.2
Divorced 25%	25			25			24.8			23.6			28			128.2			27.6
23–31.5	19.5–31.5			4.9			3.6			25–30			15.1			5.8
Job
Full-time	28	χ² = 0.4	0.25	26	χ² = 4.4	0.49	26	F = 0.66	0.33	25	F = 0.5	0.29	29.5	χ² = 3.5	0.38	129	F = 0.75	0.29	33.6	F = 1	0.37
25%	16.3–30.8			21.8–31			9.9			11			17–33.8			39.5			3.9
30 h/w	25			32			25.7			23.75			26.5			133.2			30
20.8%	20.5–31			30.5–32			1.3			4.3			22.5–31.3			10.1			3
20 h/w	26			27			27.1			25.6			30			136.8			28.2
14.7%	24–31			22–32			5.3			4.6			25–33.5			20			7.2
10 h/w	28			33			31.3			29.3			33			154			29
12.5%	27–28			30–33			2.3			4.2			31–33			10.4			4.6

Note: WBI - Work Behavior Inventory; JDI - The Job Description Index.

2.2 Measurements

Well-established tools with extensively reported psychometric properties were applied to assess the following enabling factors: motor skills, cognitive functioning, work-related self-efficacy, and work environment features. The outcome measures of work performance and job satisfaction were measured with widely used self- or collateral-report inventories.

2.2.1 Motor functioning

Three valid and reliable tools were used to assess motor functioning. First, the Modified Purdue Pegboard Test (MPPT) [39] evaluated fine dexterity through a series of four subtests: dominant hand, non-dominant hand, both hands simultaneously, and alternate hands. The participants were told to insert as many pins as they could into 2 rows of 25 holes on a board within 30 or 60 seconds while sitting. The scores reflect the number of allocating pins for each subtest [40].

Second, The Minnesota Manual Dexterity Test (MMDT) [41] was used to measure a person’s simple but rapid eye-hand coordination as well as arm-hand dexterity while standing. The test consists of two-timed subtests: (1) placing 60 short, round disks into the holes of a board with the dominant hand; and (2) turning the inserted 60 disks using both hands. Scores of each subtest reflect the total seconds required to complete each task.

Third, Physical Work Performance Evaluation (PWPE) [42] evaluated the person’s ability to perform physical work. The inventory includes 36 tasks that assess dynamic strength, posture endurance, mobility, and more. In this study, only the “LIFTING” sub-test was used, which was found by studies to predict physical ability at work [43]. The score reflects the weight (kg) that the person managed to lift before the appearance of signs of distress.

2.2.2 Cognitive functioning

The Modified Mini Mental State Examination (3Ms) [44] was used to evaluate general cognitive functioning. It consists of 27 items (19 original and 8 additional) to assess the following areas: place and time orientation, attention, concentration, long- and short-term memory, language ability, and abstract thinking. The final score is a sum of all items, while the maximum score is 100, and a score of 78 or less is indicative of cognitive impairment.

2.2.3 Self-efficacy at work

The Work-related Self-Efficacy Scale (WSS-37) [45] is a structured interview that assesses self-efficacy at work for people with psychiatric disabilities. The tool consists of 37 questions addressing self-efficacy in 4 activity areas: career planning, job acquisition, work-related social skills, and general work skills. Each item is rated on the degree of confidence he/she feels regarding the activity in the range between 0 and 100. The final score is an average of 37 questions, while a higher score indicates a higher perception of working self-efficacy.

2.2.4 Environmental assessment

NIOSH Generic Job Stress Questionnaire [46] evaluates psychosocial stressors in the work environment as perceived by the individual. The questionnaire consists of eight domains, while in this study only the following four domains were used: the Physical Environment (PE), Work Control (CS), Job Requirements (JR), and Workload (WL). Based on the previous research, we calculated two additional scores: the ratio between Control Scale and Job Requirements (CS/JR), and between Workload and Control Scale (WL/CS). In the PE domain, the respondent indicates whether each statement is true or false, while in the other domains the answer is scored on a Likert scale, ranging from 1–5. The score of each of the domains is the mean of all ratings, while some of the items’ ratings are reversed. A higher score in each domain indicates a lower level of stress.

2.2.5 Satisfaction with job

The Job Description Index (JDI) [47] examines job satisfaction according to the person’s reporting. The participant should indicate on each item whether he agrees/disagrees or he does not know. Each item is scored with 0, 1, or 3 points according to the answer. We used the 19-item version of the scale. The score ranges from 0–48, while a higher score indicates higher satisfaction with one’s work.

2.2.6 Work performance

The Work Behavior Inventory (WBI) [48] questionnaire includes 35 items that were developed to assess the behavior of a person with a psychiatric disability in the workplace. This questionnaire is intended for completion by the employer and covers the following five areas: Social Skills, Cooperation, Work Habits, Quality of Work, and Personal Appearance. Each item is scored on a 5-point Likert scale: 1- always a problematic area, and 5 - always a strong area. The total score is the sum of the items within 5 fields and overall, a higher score indicates better performance.

2.3 Procedure

People who met the inclusion and exclusion criteria were approached by the rehabilitation team. Participants who had agreed to participate in the study received a detailed explanation of the study aims and procedures and were enrolled in the study only after providing written informed consent.

The data were collected in one session lasting about two hours and included breaks as needed. The session was arranged in a location of the participants’ choice and was held in a quiet and comfortable environment. To reduce the fatigue effect on the evaluation results, the assessments were managed in a counterbalanced order. All tools for the employees were adapted to a spoken Arabic language by standard procedures before the data collection. In addition, each participant’s employer completed a questionnaire about the person’s performance at work and WBI (following the person‘s agreement and without disclosing information about his/her mental health condition).

2.4 Statistical analysis

SPSS Statistics (version 26) was used to process the study data. The level of significance for the study was 0.05. To describe the study variables, center and dispersion indices were used according to the scale type. The Shapiro–Wilk test indicated that only JDI and WBI questionnaire scores are normally distributed. Correlation analysis was done in the study with either the Spearman coefficient or the χ² test, based on the data type. The differences in the study variables according to groups of the demographic variables were investigated with the Mann–Whitney U test or the t-test, according to the data distribution. In addition, the effect size (η²) was calculated for the between-group differences.

3 Results

3.1 Descriptive analysis: Demographic data, job-related parameters, and study variables

Differences were examined in the main variables of interest by groups of demographic and job-related factors. No statistically significant differences were found in self-efficacy, environment properness, motor, and cognitive skills, as well as in the WBI and JDI scores between the IPS and sheltered factory participants (Table 2). However, an effect size of moderate strength was found for the difference in the WBI cooperation sub-scale and physical ability to lift weights in favor of IPS program participants (Table 2), while experience within the environment of job requirements and workload/control was in favor of a sheltered factory.

Table 2
Descriptive statistics of the main variables by the rehabilitation services

IPS Sheltered factory Differences

M SD M SD t η ²

MPPT

Right 11.4 2.5 10.3 2.9 0.89 0.03

Left 10.1 2.3 10.3 2.3 –0.2 0.00

Both hands 8.7 2.4 7.8 2.6 0.73 0.02

Assembly 22.2 6.7 18.5 8.2 1.1 0.05

WSS-37 74.6 13.9 72 12.8 0.39 0.00

NIOSH

Physical environment 1.3 0.2 1.3 0.23 0.2 0.00

Control scale 2.5 0.9 2.7 0.8 –0.5 0.01

Job requirements 3.5 0.9 4.1 0.5 –1.9 0.08

Workload 2.7 0.5 2.5 0.1 1 0.02

Control scale/job requirements 0.8 0.3 0.7 0.2 0.4 0.00

Workload/ control scale 1.2 0.4 0.9 0.2 1.3 0.07

WBI

Final score 139.1 25 132.5 16 0.59 0.02

Work habits 28.1 6 25.3 4.4 1 0.05

Quality of work 25.9 7 25 3 0.4 0.00

JDI 29.6 5.2 30.5 7.4 –0.03 0.00

Median Quarterly range Median Quarterly range U η ²

WBI

Social skills 27.5 23.5–30.2 28 23–31 39.5 0.00

Cooperation 31 24.8–33 29 20.3–31.3 27 0.07

Personal presentation 30.5 27–34.3 28 23.5–31.5 30.5 0.02

PWPE 15 8.8–15 8.8 3.8–15 32 0.1

MMDT

Turning 86.2 66.5–105.6 86.3 74–134 43 0.03

Placing 86.6 78.6–99.4 88.3 79.7–105.4 41 0.03

3Ms 87 78–94.2 88.5 77.8–95 49 0.00

	IPS	Sheltered factory	Differences
MPPT
Right	11.4	2.5	10.3	2.9	0.89	0.03
Left	10.1	2.3	10.3	2.3	–0.2	0.00
Both hands	8.7	2.4	7.8	2.6	0.73	0.02
Assembly	22.2	6.7	18.5	8.2	1.1	0.05
WSS-37	74.6	13.9	72	12.8	0.39	0.00
NIOSH
Physical environment	1.3	0.2	1.3	0.23	0.2	0.00
Control scale	2.5	0.9	2.7	0.8	–0.5	0.01
Job requirements	3.5	0.9	4.1	0.5	–1.9	0.08
Workload	2.7	0.5	2.5	0.1	1	0.02
Control scale/job requirements	0.8	0.3	0.7	0.2	0.4	0.00
Workload/ control scale	1.2	0.4	0.9	0.2	1.3	0.07
WBI
Final score	139.1	25	132.5	16	0.59	0.02
Work habits	28.1	6	25.3	4.4	1	0.05
Quality of work	25.9	7	25	3	0.4	0.00
JDI	29.6	5.2	30.5	7.4	–0.03	0.00
	Median	Quarterly range	Median	Quarterly range	U	η ²
WBI
Social skills	27.5	23.5–30.2	28	23–31	39.5	0.00
Cooperation	31	24.8–33	29	20.3–31.3	27	0.07
Personal presentation	30.5	27–34.3	28	23.5–31.5	30.5	0.02
PWPE	15	8.8–15	8.8	3.8–15	32	0.1
MMDT
Turning	86.2	66.5–105.6	86.3	74–134	43	0.03
Placing	86.6	78.6–99.4	88.3	79.7–105.4	41	0.03
3Ms	87	78–94.2	88.5	77.8–95	49	0.00

Note: WBI - Work Behavior Inventory; JDI - The Job Description Index; NIOSH - NIOSH Generic Job Stress Questionnaire; 3Ms - Modified Mini Mental State Examination; WSS-37 - Work-related Self-Efficacy Scale; PWPE - Physical Work Performance Evaluation; MMDT - Minnesota Manual Dexterity Test; MPPT - Modified Purdue Pegboard Test.

No statistically significant differences were found between the men and women in the JDI and the WBI indices, but a moderate strength effect size was found for the difference in the total WBI score and four sub-scales of the questionnaire (Table 1) in favor of the women. Interestingly, no significant effect size was found for the social skills between the men and women (Table 1).

No statistically significant differences were found between the participants who reported a sense of occupational balance and those who did not in the WBI and JDI scores (Table 1). However, strong effect size for the difference was found in the JDI score and moderate effect size was found for the difference in the cooperation scale of WBI. People who experienced occupational balance tend to report higher satisfaction at work and their cooperation is rated higher by their employer (Table 1).

No significant differences were found between different types of marital status (single, married, or divorced) in the JDI score and the total WBI score (Table 1). Still, the effect size showed moderate-high differences between the groups in the total WBI score, as well as in the following indices: personal presentation, quality of work, work habits, and cooperation in favor of the married participants (Table 1).

No significant differences were found between participants who had meaningful relationships at work and those who did not, and the participants who reported having social relationships at work in general and those who have not in WBI and JDI (Table 1) and self-efficacy assessed by the WSS-37 questionnaire (t(21) = 0.7, p > 0.05; η² = 0.03). However, the effect size metrics detected a moderate to strong between-groups difference in the self-efficacy and in the JDI score in favor of the people who reported having meaningful relationships at work and in favor of the participants who reported social relationships at work (Table 1). In addition, moderate strength differences were found between the groups in most of the WBI indices. Surprisingly, people who reported having meaningful relationships or social relationships at work were rated lower in work functioning by their employer (Table 1).

No differences were found between the full-time and part-time employment (10, 20 or 30 hours a week) in WBI and JDI (Table 1) and self-efficacy (F(18,3) = 0.9, p > 0.05; η² = 0.1). However, moderate to strong effect size was found for the difference in the JDI and WSS-37 scores (Table 1). People employed on full-time jobs indicated higher job satisfaction and self-efficacy. Moreover, the effect size metrics detected a moderate to strong between-group difference in most of the WBI indices. People employed 10 hours a week were rated higher by their employer in most of the WBI indices(Table 1).

No significant correlations were found between outcome measures and demographic and job-related variables, except for a moderate positive correlation between the age of mental illness onset and the quality of work as assessed by the employer (WBI) (Table 3). The older the age of the onset, the higher the quality of work according to the employer’s report. In addition, a positive correlation of a moderate strength was found between monthly wage and self-efficacy. The higher the wage, the higher self-efficacy demonstrated at work.

Table 3

Correlation between the outcome measures and the demographic variables

		WBI
Demographic variables	JDI	Social skills	Cooperation	Work habits	Quality of work	Personal appearance	Final score
Age	–0.11	–0.27	–0.03	0.2	0.2	0.04	0.05
Years of education	–0.22	0.24	0.33	0.3	0.37	0.39	0.34
Age of illness onset	–0.13	0.25	0.07	0.34	0.45^*	0.29	0.41
Duration of rehabilitation services (month)	0.4	–0.21	0.03	–0.22	–0.34	–0.23	–0.31
Work (months)	–0.21	–0.19	0.05	0.25	0.19	0.04	0.09
Employment services duration (months)	0.09	–0.27	–0.17	–0.15	–0.18	–0.23	–0.24
Work hours per week	0.31	0.05	–0.11	–0.12	–0.11	–0.13	–0.08

Note: ^*p < 0.05; WBI - Work Behavior Inventory; JDI - The Job Description Index.

3.2 Association between enabling factors and employment outcomes

The hypothesis on the correlation between the enabling factors (motor functioning, cognitive skills, self-efficacy, and subjective assessment of the work environment) and outcome measures (level of performance and satisfaction with the job) has not been largely confirmed. No significant correlations were found between the level of performance at work according to the employer report (WBI) and motor skills (according to results of the three motor examinations: PWPE, MMDT [Placing and Turning test], and MPPT [all subtests]), cognitive abilities (MS3), and self-efficacy (WSS-37) (Table 4).

Table 4
Correlations between outcome measures and motor, cognitive, self-efficacy, and environmental factors

Assessment WBI JDI (N = 23)

Social skills (N = 20) Cooperation (N = 20) Work habits (N = 20) Quality of work (N = 20) Personal presentation (N = 20) Final score (N = 20)

MMDT

Placing –0.215 0.1320 0.0590 –0.076 –0.135 –0.082 –0.264

Turning 0.1330 0.002 0.1020 –0.022 –0.197 0.0220 –0.291

MPPT

Right –0.035 –0.144 –0.381 –0.338 –0.059 –0.279 0.4050

Left –0.061 –0.286 –0.319 –0.158 –0.013 –0.259 0.0470

Both hands 0.1620 –0.212 –0.396 –0.350 –0.032 –0.226 0.4010

Assembly –0.053 0.0180 –0.089 –0.107 0.1800 –0.001 0.390

PWPE 0.041 –0.099 –0.433 –0.384 –0.077 –0.213 0.366

WSS-37 –0.217 –0.027 –0.352 –0.436 –0.188 –0.372 0.617^

3Ms –0.205 0.1600 0.094 0.2370 0.289 0.065 0.005

NIOSH

Physical environment –0.055 –0.111 0.0430 0.0700 –0.087 –0.033 –0.331

Control scale 0.1540 –0.171 –0.388 –0.152 –0.055 –0.236 0.535^

N = 19 N = 19 N = 19 N = 19 N = 19 N = 19 N = 22

Job requirements 0.2900 0.011 –0.287 –0.136 0.1030 –0.101 0.093

Workload –0.096 –0.087 0.174 0.227 0.087 0.213 0.301

Control scale/job requirements 0.023 –0.031 –0.040 0.010 –0.224 –0.115 0.373

Workload/control scale –0.145 0.116 0.450 0.301 0.099 0.335 –0.454^*

Assessment		WBI	JDI (N = 23)
MMDT
	Placing	–0.215	0.1320	0.0590	–0.076	–0.135	–0.082	–0.264
	Turning	0.1330	0.002	0.1020	–0.022	–0.197	0.0220	–0.291
MPPT
	Right	–0.035	–0.144	–0.381	–0.338	–0.059	–0.279	0.4050
	Left	–0.061	–0.286	–0.319	–0.158	–0.013	–0.259	0.0470
	Both hands	0.1620	–0.212	–0.396	–0.350	–0.032	–0.226	0.4010
	Assembly	–0.053	0.0180	–0.089	–0.107	0.1800	–0.001	0.390
PWPE		0.041	–0.099	–0.433	–0.384	–0.077	–0.213	0.366
WSS-37		–0.217	–0.027	–0.352	–0.436	–0.188	–0.372	0.617^**
3Ms		–0.205	0.1600	0.094	0.2370	0.289	0.065	0.005
NIOSH
	Physical environment	–0.055	–0.111	0.0430	0.0700	–0.087	–0.033	–0.331
	Control scale	0.1540	–0.171	–0.388	–0.152	–0.055	–0.236	0.535^**
		N = 19	N = 19	N = 19	N = 19	N = 19	N = 19	N = 22
	Job requirements	0.2900	0.011	–0.287	–0.136	0.1030	–0.101	0.093
	Workload	–0.096	–0.087	0.174	0.227	0.087	0.213	0.301
	Control scale/job requirements	0.023	–0.031	–0.040	0.010	–0.224	–0.115	0.373
	Workload/control scale	–0.145	0.116	0.450	0.301	0.099	0.335	–0.454^*

Note: ^*p < 0.05, ^**p < 0.01; WBI - Work Behavior Inventory; JDI - The Job Description Index; NIOSH - NIOSH Generic Job Stress Questionnaire; 3Ms - Modified Mini Mental State Examination; WSS-37 - Work-related Self-Efficacy Scale; PWPE - Physical Work Performance Evaluation; MMDT - Minnesota Manual Dexterity Test; MPPT - Modified Purdue Pegboard Test.

No significant correlations were found between job satisfaction, as measured with JDI, and motor skills evaluated with three assessments (PWPE, MMDT, and MPPT) (Table 4). In addition, no significant correlations were found between JDI and general cognitive status as assessed by 3Ms (Table 4). In contrast, a strong positive correlation was found between JDI and the WSS-37 scores. The higher the person‘s self-efficacy at work, the higher the job satisfaction (Table 4).

A moderately positive correlation was found between the JDI and the control sub-scales of the NIOSH questionnaire (Table 4). In addition, WL/CS was found to be moderately, and negatively correlated with the JDI. The lower personal control on the work load, the lower the job satisfaction (Table 4). No correlations were found between JDI and additional NIOSH indices (Table 4) or the WBI questionnaire.

4 Discussion

This study is the first one to investigate an association between a range of employment enablers within person, environment, and work and employment outcomes. More specifically, we examined the correlation between cognition, work-related self-efficacy, motor skills, environment features at work, and job satisfaction and level of functioning. This was previously demonstrated in Western societies as well as among the Jewish population of Israel with SMI [31, 32]. The findings reveal both unique and universal characteristics of the Arab population of East Jerusalem within vocational rehabilitation. The results refuted most of the established patterns of the association between personal factors, demographic variables, environmental aspects, job features, and outcome measures of job satisfaction and level of functioning. Still, some of the previously established patterns were approved, suggesting new pathways of the interplay between the factors. The findings support the notion of cultural influences on employment outcomes and vocational rehabilitation [25, 26], suggesting a need for cultural adaptation of existing standardized vocational rehabilitation services in Israel for the Arab population of East Jerusalem.

Contrary to studies with Western and Jewish Israeli populations [31 , 49], no association was found between functioning in both sheltered and competitive workplace (IPS services) and a worker’s cognitive, motor, or emotional skills. These findings may be explained in light of the cultural and socio-political context of this population [50]. Being at the bottom of the labor-market pyramid as an ethnic and health-status minority, the work options are limited and factors other than personal talent and skill determine work choices and preferences, further influencing both functioning and satisfaction. These factors may be a readiness to work in any job offered being a minority, an urgent need for any income, a desire or need to work with Arab colleagues because of cultural, social, and language issues, or cultural values of job position and related activities according to culturally established social roles. The impact of these factors is so ingrained that even though the vocational rehabilitation services are graded in Israel based on level of individual functioning and skills with higher demands for IPS services, no differences were found either in personal skills, including work-related self-efficacy or in the level of functioning at a job between the IPS and sheltered factory services’ participants from the Arab population.

Still, the findings may be explained by the methodological issues of the study. The level of functioning was estimated based on the employee report on a well-established and commonly used scale—the Work Behavior Inventory. The instrument was completed in the sheltered factory by rehabilitation workers who received education in the field of mental health rehabilitation and recovery competencies where the emphasis was on the quality of the vocational rehabilitation process. In the IPS service (competitive employment), the instrument was completed by the employer without vocational rehabilitation-specific knowledge, with the emphasis being placed on productivity and outcome. Thus, it may be assumed that the lack of difference between the services stems from a divergence in employers’ backgrounds and approaches. Both are possible: the rehabilitation workers rated the employees’ functioning higher in the sheltered factory setting, spotlighting aspects of his rehabilitation process, whereas the employer in a competitive job rated the employees’ functioning lower as they focused on the general idea of productivity. All the presented arguments do not eliminate the issue of cultural relevance and sensitivity of the WBI instrument. As the tests were developed in the West with a specific vision and values for the role and quality of the worker, they may not capture non-Western vision and values, causing biases in the study.

The findings of no association between individual motor and cognitive skills and personal satisfaction with a job may be explained similarly, further discovering the impact of cultural diversity. It may be assumed that the work choices of the Arab population of East Jerusalem, which are critical for job integration and tenure [51], are guided by different factors than personal skills and talents. Thus, other aspects may contribute to the satisfaction of this population. These unique characteristics are even more prominent in light of additional findings on the lack of association between wage level and job satisfaction.

In addition, there is an issue as to the cultural appropriateness of the job satisfaction scale for the investigated population as well. The concept of “satisfaction” is abstract- and culture-dependent in its nature [52, 53]. Measuring satisfaction in the context of work, with a population with considerable cultural issues, using general tools is even more challenging. However, following previous research within Western populations [54, 55], we found that higher job satisfaction is associated with higher self-efficacy and a higher level of control over the work and experience of the workload. This finding suggests a mutual relationship between the variables. Interestingly, contrary to the previous research in the field [55], no additional associations between job satisfaction and job environment qualifiers were found.

One example of a factor that we found to be associated with job satisfaction is the general experience of occupational balance. This finding is in line with previous research in the field [6] and suggests an importance in the vision of work within a general occupational landscape of the individual’s life, rather than being a stand-alone issue requiring rehabilitation. Thus, the structure of rehabilitation services, divided by areas of occupation, as accepted in Israel, i.e., vocational rehabilitation deals with direct job-related issues only, may be less relevant for this population. Following previous research [56], we found that job satisfaction is associated with social connectedness and having a meaningful relationship with other people in the workplace. Surprisingly, we found that social connectedness reduced the level of functioning according to employers’ reports. It may be assumed that people with limited experience of connectedness feel less safe in the workplace and seek to achieve safety, investing much more effort in meeting job requirements and employer expectations.

Additional findings demonstrate a complex interplay between the work-related outcomes of individual satisfaction with a job and level of functioning at a workplace revealing both unique and shared characteristics in this population. People working a full-time job experienced a higher level of satisfaction with the job and self-efficacy, being evaluated significantly lower by the employer on their level of functioning compared to those who work a part-time job. Even though the research on job satisfaction is in its infancy in all populations [52], both outcomes are important within the process of vocational rehabilitation. The incongruity in findings highlights a need to address both the employee’s and employer’s vision to understand comprehensively the employment situation. Next, neither job satisfaction nor the level of functioning was associated with the level of education, duration of rehabilitation services’ support, or job tenure further raising a question on both understanding the employment phenomenon among the Arab population of East Jerusalem and suitability of the current format of rehabilitation services for the investigated population.

The shared characteristics that were found in this study between the Arab population of East Jerusalem and the Western populations in the context of employment included an association between level of wage and self-efficacy [57] and age of illness onset with the level of functioning [58, 59]. In addition, the finding suggests the gender- and marital status-dependent differences in the level of work functioning. The differences may be even more prominent in the investigated population in comparison to the Western population given more ingrained differences in traditional gender and family roles that are deeply embedded within the general cultural context [20 , 26]. The study has several limitations. The number of participants in the current study was small with no equal representation of shelter and competitive employment groups and gender. The small sample represents general trends of little service use in the investigated population, still, it interferes with drawing conclusions. Even though the linguistic issues were resolved for this study, involving either fluently Hebrew-speaking employers or using the Arabic language version of tools for employees, the cultural aspects were presented within the tools. Since these tools were not specifically developed for this population, this might lead to biases in the study results. The lack of a control group in this study limited the strength of a conclusion on cultural impact versus health condition-related impact.

5 Conclusion

The results reveal that the Arab population of East Jerusalem shares some similar characteristics with the Western and Jewish Israeli population, but largely has unique characteristics in the context of employment and vocational rehabilitation. This pioneering exploratory study demonstrated distinctive patterns of association between personal factors, environment, and job characteristics and the level of functioning at work and job satisfaction from those patterns which were previously reported in other populations. Being both an ethnic and health status minority, the discrepancy in the findings suggests the impact of cultural issues. Since this impact of cultural issues on vocational rehabilitation was scarcely investigated in this population, the findings raise an urgent need to establish the research line for (1) investigation of culturally relevant constructs and concepts in the field of employment and vocational rehabilitation within the broad context of individual occupations; (2) development of tools addressing cultural uniqueness of Arab population of East Jerusalem; and (3) further exploration of a complex interplay between multiple factors. Such a research line will provide information for the development of culturally relevant, sensitive, and safe services for the Arab population of East Jerusalem, limiting the impact of cultural disparity and providing real opportunities for meaningful employment, and supporting the recovery and well-being of this population.

Footnotes

Acknowledgments

The authors are grateful to all study participants for taking part in the research procedures. In addition, they would like to thank the Udi Marili Supported Employment Organization and staff for their support in data collection.

In addition, we would like to thank Prof. Navah Z. Ratzon for her expertise in the fields of work and ergonomics and for her contribution as a consultant.

Conflict of interest

The authors declare that they have no conflict of interest.

The study was done as part of MS degree in Occupational Therapy at the School of Health Profession, Sackler Faculty of Medicine, Tel Aviv University, Israel.

Funding

The authors report no funding.

Informed consent

All study participants provided informed consent to participate in the study according to the Declaration of Helsinki.

Ethical approval

The study received ethical approval from the Psychiatric Rehabilitation Department of the Israeli Ministry of Health and the Ethics Committee of Tel Aviv University (approval number: 20181129, date: 29/11/2018).

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Assessment		WBI						JDI (N = 23)
		Social skills (N = 20)	Cooperation (N = 20)	Work habits (N = 20)	Quality of work (N = 20)	Personal presentation (N = 20)	Final score (N = 20)
MMDT
	Placing	–0.215	0.1320	0.0590	–0.076	–0.135	–0.082	–0.264
	Turning	0.1330	0.002	0.1020	–0.022	–0.197	0.0220	–0.291
MPPT
	Right	–0.035	–0.144	–0.381	–0.338	–0.059	–0.279	0.4050
	Left	–0.061	–0.286	–0.319	–0.158	–0.013	–0.259	0.0470
	Both hands	0.1620	–0.212	–0.396	–0.350	–0.032	–0.226	0.4010
	Assembly	–0.053	0.0180	–0.089	–0.107	0.1800	–0.001	0.390
PWPE		0.041	–0.099	–0.433	–0.384	–0.077	–0.213	0.366
WSS-37		–0.217	–0.027	–0.352	–0.436	–0.188	–0.372	0.617^**
3Ms		–0.205	0.1600	0.094	0.2370	0.289	0.065	0.005
NIOSH
	Physical environment	–0.055	–0.111	0.0430	0.0700	–0.087	–0.033	–0.331
	Control scale	0.1540	–0.171	–0.388	–0.152	–0.055	–0.236	0.535^**
		N = 19	N = 19	N = 19	N = 19	N = 19	N = 19	N = 22
	Job requirements	0.2900	0.011	–0.287	–0.136	0.1030	–0.101	0.093
	Workload	–0.096	–0.087	0.174	0.227	0.087	0.213	0.301
	Control scale/job requirements	0.023	–0.031	–0.040	0.010	–0.224	–0.115	0.373
	Workload/control scale	–0.145	0.116	0.450	0.301	0.099	0.335	–0.454^*