Exploring the experiences of women with acquired brain injury on return to work and entrepreneurial skills development in the Western Cape Metropolitan,South Africa

Abstract

BACKGROUND:

Acquired brain injury (ABI) is an important public health problem. Individuals with ABI experience greater challenges with community reintegration and successful return to work (RTW) due to both personal and environmental factors. Empirical evidence has shown that women with brain injury are vulnerable to poorer functional outcomes and have demonstrated lower RTW rates post-injury. Therefore, further research is needed to gain greater insight on women with acquired brain injury’s functional and work abilities as well as their experiences of RTW and entrepreneurial skills development.

OBJECTIVE:

This study aimed to explore and describe women with acquired brain injury’s experiences during their rehabilitation process, their resumption of their worker role, and entrepreneurial skills development. This qualitative exploration formed part of a study that resulted in an occupational therapy practice model to enhance the entrepreneurial skills of women with acquired brain injury living in the Cape Metropolitan, Western Cape, South Africa.

METHODS:

Semi-structured interviews were conducted with ten females with acquired brain injury. A qualitative approach was employed to thematically analyse the data.

RESULTS:

Three themes emerged from the study: (1) Barriers within the rehabilitation process, 2) ABI causes loss of a sense of self and financial strain, 3) Entrepreneurship and education as a strategy to empowerment.

CONCLUSION:

Unmet individual needs related to occupational engagement results in RTW challenges for women with ABI. ABI sequelae cause activity limitations and hinder gainful occupational participation. A holistic client-centred entrepreneurial skills development approach is a viable and needed strategy to facilitate economic empowerment for women with ABI.

Keywords

Client-centred self-efficacy entrepreneurial skills empowerment

1 Introduction

The global estimated occurrence of all causes of acquired brain injury (ABI) are at approximately 939 cases per every 100,000 people [1]. ABI inflicts varying degrees of participation restrictions in all spheres of life, especially with regard to resuming work post- injury [2]. Thus, investigating return to work (RTW) as an interface between motivation, individual needs as well as the available supports in the social, economic and vocational environments have been found to be essential in employment outcomes [3 –5]. A paucity on clinical research on brain injury that examines the construct of sex and gender and its relation to health and work reintegration of women have been empirically noted [4, 5]. Similarly, a systematic review by Cancelliere, Donovan and Cassidy [6], with gender as an indicator of prognosis after mild traumatic brain injury (TBI), found that only 7% of >200 of the studies that were reviewed provided data stratified by gender. Data sets are still not balanced of suitable size to allow women to be addressed in investigative approaches. Women with ABI’s experience difficulty in their daily lives due to impairment related factors which negatively influence their participation in activities of daily living [7] and have also demonstrated a higher likelihood of not resuming their work roles within a year post-injury compared to men with ABI. This is often attributed to both personal and environmental risk factors including facing discrimination and gender norms that exist within particular workplaces [4, 8]. The research findings on intersectionality in disability and gender highlights that disability and gender interacts causing negative outcomes for women and people with disabilities, more so for black women living with disabilities [9]. In South Africa a higher disability rate and prevalence among women compared to men have been documented at 8.3% and 6.5% respectively [10]. The country’s National Development Plan reported that some households such as those of women with disabilities, individuals with severe disabilities as well as those with children with disabilities, continues to remain vulnerable and economically disadvantaged [11]. According to Rogan [12] the high poverty rate among women in South Africa is as a result of the disadvantages faced in the labour market. South Africa’s public health sector attends to the bulk of the population’s health needs in spite of limited financial and human resources. Yet, there continues to remain a gap in a collaborative inter-sectoral approach to achieving equitable and inclusive services to advance optimal health and well-being amongst the country’s most vulnerable groups [13, 14]. While entrepreneurship is recognised as a viable strategy that can contribute to South Africa’s development concerns and economic progress [15, 16], there continues to remain a dearth in literature on entrepreneurial skills development and entrepreneurship interventions for women with ABI [16]. Particularly in the South African context, redefining women with ABI’s experience of disablement in the employment market by means of entrepreneurship education and skills training could enhance their functional and work abilities towards a more progressive economic stance[14 , 17].

2 Materials and method

The study utilised a qualitative approach employing an exploratory and descriptive design. The impetus to conduct the study was to explore and describe the experiences of women with ABI during their rehabilitation process, their resumption to work and entrepreneurial skills development. We also wanted to find out how and why their health problem impacted on their daily function, post-injury behaviour, participation restrictions as well the influence that environmental factors had on occupational performance and participation [18].

2.1 Participants

A purposive sampling technique was used to select the participants grounded on the study’s purpose and stipulated inclusion criteria [19]. A total of 10 females who received a clinical diagnosis of ABI were sampled from two designated work assessment units (WAU) at Groote Schuur and Tygerberg Hospital (GSH and TBH), Western Cape, South Africa. Sampling was refined based on the participants’ medical records and ICD-10 diagnosis code, which is part of a coding system that communicates health data in a consistent and reproducible manner [20]. See Tables 1 and 2 for the inclusion criteria and participant demographic information.

Table 1
Criteria for participant selection

Inclusion Exclusion

Women between 18 and 65 years, who had worked pre-morbidly in the formal labour market Those with psychiatric conditions or other medical conditions that might have an influence on the sequelae of ABI were excluded.

Must have worked pre-morbidly in the formal labour market

Had been diagnosed with ABI with a post-acute brain injury stage of recovery of approximately four to six months

Must have received curative and rehabilitation services including physio, psychological, speech and/or occupational therapy.

Adequate cognitive ability to independently perform their daily activities

Able to understand and communicate in either the English, Afrikaans or Xhosa languages

Inclusion	Exclusion
Women between 18 and 65 years, who had worked pre-morbidly in the formal labour market	Those with psychiatric conditions or other medical conditions that might have an influence on the sequelae of ABI were excluded.
Must have worked pre-morbidly in the formal labour market
Had been diagnosed with ABI with a post-acute brain injury stage of recovery of approximately four to six months
Must have received curative and rehabilitation services including physio, psychological, speech and/or occupational therapy.
Adequate cognitive ability to independently perform their daily activities
Able to understand and communicate in either the English, Afrikaans or Xhosa languages

Table 2

Participants demographic characteristics

Names	Age	Education	Marital status	Diagnosis	Employment prior to injury	Difficulties after ABI	RTW after ABI
Participant 1: SE	57	Grade 10	Married	Brain aneurysm	Self-employed	Poor vision, memory and emotional difficulties	No
Participant 2: ES	45	Grade 10	Single	Brain tumour	Machinist	Memory and concentration difficulties	RTW as a cashier (14 months post ABI)
Participant 3: LBO	41	Grade 10	Single	Left cerebral vascular accident (CVA)	CCTV security guard	Right upper limb weakness, cognitive and emotional difficulties	RTW in same capacity (4 months’ post ABI). Currently unemployed after resignation
Participant 4: NR	29	Grade 11	Single	Moderate TBI	Bar lady	Short term memory and concentration difficulties	Learnership programme (Private organisation)
Participant 5: LB	36	Tertiary education	Single	Moderate TBI	Jewellery designer and manufacturer	speech and cognitive difficulties	Self-employed
Participant 6: VG	48	Grade 10	Single	pituitary brain tumour	Machinist	Changes in mood, poor memory as well as frequent fatigue	RTW in same job (resigned 6 months post RTW) currently unemployed
Participant 7: CW	24	Grade 12	Single	Mild TBI	Receptionist	Concentration and memory difficulties	RTW as receptionist (two years post ABI)
Participant 8: BW	42	Grade 10	Single	Moderate TBI	Hair dresser	Post-traumatic stress symptoms	Unemployed
Participant 9: EH	42	Grade 7	Married	left cerebral vascular accident	Domestic worker	Spastic right hand and cognitive difficulties	Unemployed
Participant 10: EB	28	Grade 10	Married	Right cerebral vascular accident	Administrative assistant	Mild cognitive difficulties, psychological and emotional difficulties	Unemployed

2.2 Procedure

The study participants were contacted telephonically and once verbal confirmation for participation was obtained an introductory meeting was arranged to further obtain signed consent. Face-to-face semi-structured interviews were held with each participant that lasted approximately 45–60 minutes. Two of the participants were interviewed at Groote Schuur Hospital and three were interviewed at Tygerberg Hospital. The rest of the participants were interviewed at venues closer to their homes that included the public library and small coffee shops. All the study participants were provided a stipend to cover any travelling expenses incurred by them to attend the interviews. The interviews were conducted in both English and Afrikaans which allowed us to uncover and reveal the deeper meanings, beliefs, perceptions and experiences of the study participants post-ABI. The interviewing techniques were applied by posing a broad, open-ended question to allow the participants to freely speak and in a casual manner. During the interviews, we observed participants’ facial expressions, body language and tone of voice while making brief notes on key areas of concerns brought up by participants. The facial expressions of the participants allowed us to identify the feeling that the participants related to the challenges that they experience when trying to find employment in the open labour market. Permission from the participants was obtained to record the conversations which were later transcribed verbatim by an individual skilled in the task. A subsequent follow-up interview was arranged with two of the participants to gain additional information and clarity on their situations. According to Charmaz [21], the knowledge of saturation originated from the grounded theory and saturation during qualitative data collection occurs when you stop collecting data because fresh data no longer triggers new insights. Hence, the point of saturation of this study became evident after interviewing ten participants and no new patterns or themes emerged.

2.3 Analysis

Thematic analysis was used to analyse the qualitative data [22]. To ensure data quality, a researcher who is fluent in both English and Afrikaans analysed all transcripts in the conversed language of the participants during the interviews. In order to minimise the risk of misinterpretation and loss of the Afrikaans-speaking participants’ intended meanings, we captured their original words, phrases, and connotations. Thereafter we analysed the Afrikaans transcripts and later translated it to English to convey its linguistic equivalence. Whilst adopting a method adapted from among others, Tesch [23], the researcher read through all the transcripts several times to obtain a thorough understanding of the information recorded from the participants. By capturing the underlying meaning of texts in the transcripts we gained greater insight on the perceptions and experiences of the study participants. Subsequently, descriptions and direct quotes depicting similarities in meaning were collected to form categories. Following the careful analysis procedure and referring to the relevant literature we were able to establish theoretical patterns of relationships between emerging categories. A deductive and inductive reasoning approach was utilised to elucidate emerging themes that developed from the data. To safeguard and establish trustworthiness and rigour of the current study, aspects of trustworthiness in Guba’s Model as recommended by Krefting [24, 25] was employed. Data triangulation was used to ensure that the information that were collected is reliable. Data collection methods included interviews with the study participants, our objective and structured observations as well as the critical reflective records. To ensure the truthfulness and originality of the data, no modification or editing to the interview transcripts were made in order to preserve the rich and authentic perspectives and lived experiences of the study participants. Member checking consisted of taking data and interpretations back to the study participants to authenticate the information of their narratives. By providing dense descriptions of the study participants, the detailed data collection methods, as well as a thorough description of the data analysis and procedures, transferability was confirmed. Any personal biases were bracketed to ensure that the findings were a true reflection of the study participants’ experiences. The neutrality criterion was ensured by presenting the data in a manner that methods and processes could be tracked and audited.

2.4 Ethics

This study adhered to the 2008 Declaration of Helsinki that guides the conduct of medical research involving human participants. Permission and ethical clearance were obtained from the University of Western Cape Research and Ethics Committee. Ethical clearance was granted by the Groote Schuur Hospital and Tygerberg Hospital’s ethics committees to conduct the research at the two designated Work Assessment Units. The following guidelines were used: i) The purpose of the study was clearly explained to the study participants, signed and informed consent was sought from all participants; ii) The participants were informed that their participation is voluntary and that they have a right to withdraw from the study at any time; iii) The participants’ anonymity was ensured by using identification codes on all data forms; iv) All forms and questionnaires were collected by the researcher who was responsible for storing it in a locked and secure place; v) All the audio recordings were deleted after they had been fully transcribed and documented; vi) Pseudonyms were also used to protect the participant’s identities; vii) Few risks were expected to be encountered in the current study. The current study was approved by the Institutional Review Board of the University of the Western Cape (Ethics number: BM17/8/7).

3 Results

Three themes emerged from the study namely, Theme one: Barriers within the rehabilitation process; Theme two: ABI causes loss of a sense of self and financial strain; Theme three: Entrepreneurship and education as a strategy to empowerment.Figure 1 presents a description of the themes and related categories.

Fig. 1

Diagrammatical presentation of the perceived barriers and enablers to work and entrepreneurial skills development after ABI.

3.1 Barriers within the rehabilitation process

This theme represents the participants’ experiences during their rehabilitation and return to work process post-ABI.

Category one: Communication oversights during rehabilitation

This category describes the participants’ lack of understanding and uncertainty of the influence their ABI had on their future employability and vocational goals. One participant described her experience and stated:

“The doctor did not tell me why he sent me for a work assessment, it actually was to find out if I am eligible for a disability grant, but I feel they could have done more (provide more information and guidance to the ABI diagnosis), I don’t know if I was wrong to expect that” P1

Participants stated that after their work assessment there were minimal communication regarding options and opportunities to return to work or any other form of gainful employment. One participant stated:

“There was nothing I could depend on; they offered nothing that could assist in building up my self-esteem or something like that. There was not even maybe I could learn again to do A, B and C ... there was nothing. According to them I was fit for work and there was no follow-up” P3

Category two: Difficulty coping during return to work

The study participants reported that in spite of being declared fit for work, their attempts to successfully integrate into their old jobs or any new jobs was extremely challenging. A participant said:

“I did not feel fit for work, but I had to go work to support my children financially” P6

The participants who returned to work expressed that they experienced difficulty performing work duties due to not being equipped with the necessary adaptive strategies and skills to manage their work tasks. One participant reported:

“It was very difficult for me to work, every time when I sit behind the sewing machine then my feet become painful and swollen, that is why it was difficult because I could not understand why. You struggle, it was hectic, there is a production target that you need to meet and sometimes you cannot meet the target. I just became tired so quickly but then the doctor says you healthy, but I don’t feel healthy” P2

The participants experienced difficulty coping during demanding work situations which exacerbated their anxiety levels. Lack of workplace support and negative feedback on work performance further demotivated the study participants in their worker role. A participant stated:

“There were too many stressful things that I just could not cope with and do. But the employer did not move me to a smaller department. The manager even said you don’t come in my shop ... leave, because how can they (health team) allow someone that had a stroke three weeks ago come back to work in this shop’. This damaged my self-esteem. I forgot how to do certain things in my work” P3

3.2 ABI causes loss of a sense of self and financial strain

In this theme participants expressed how their ABI impacted on the “self” and depicts how the related impairments of the injury inflicted imbalance on their daily occupations and their livelihood. The theme also revealed that a good social support system positively influenced the participants’ occupational performance post-ABI.

Category one: Diminished trust in the self

In this category the participants reported that apart from experiencing the external factors that impacted on their RTW, they became aware of the internal processes that occurred within their own self. They reported that ABI related impairments had a negative effect on most aspects in in their lives. A participant stated:

“I am busy with something then the next minute or two, then I don’t know what I was busy with or what I wanted to do, or where I have left things, it is difficult” P6

Participants reported that one of the most prominent difficulties they experienced post-ABI, is the trust they have lost in their own self. A participant stated:

“I struggle to trust that I am doing the right thing. I don’t trust myself ... and I think the fact that I don’t trust myself is when I am doing something wrong and how people will react to me when I’m doing it wrong” P4

A participant stated she felt anxious as she always anticipated failure in tasks and activities, she engaged in. She stated:

“I know I will not be able to keep up ... it doesn’t matter what I am busy with” P6

Category two: The burdensome time gap between ABI and RTW

The above category describes the adverse effects of unemployment post-ABI. The participants reported that apart from experiencing financial burden they also experienced a loss of ambitious drive and motivation. Most participants reported that they did not receive any form of financial assistance as their symptoms or impairments were not substantial enough to warrant a state disability grant. A participant stated:

“I was without an income for a year and seven months, I was under so much pressure” P10

Participants reported how their loss of income also impacted on their family members’ livelihood needs. This reflects in one participant’s statement:

“Do you know what it is to work my dear? to support your family financially.? I am still choking on an electricity bill and I need to pay my daughter’s college fees. It was a year of sitting (not working) that made me very irritated and emotional because there was not much I could do about my situation” P1

Category Three: Social support enhances occupational engagement

This category represents the supportive and motivating role of the participants’ family and friends post-ABI. The participants reported that support from family and community members motivated them to work towards gaining functional independence. A participant reported on the support she received by stating:

“My mother at that time was like my memory, and she still is. We never had a good relationship but after the accident she supported me in everything. She would remind me of lots of things I would tend to forget. My mom would make sure that I get to my appointments and reminded me of things all the time. She would even talk on the phone on my behalf. I feel we definitely became closer” P4

Another participant expressed how the support from her spouse helped her to become more motivated towards her recovery and how she eventually became more involved in an informal small business initiative. She stated:

“My husband supported me during the time I was at home after my stroke. He went the extra mile and even worked during his off days to earn extra money so that I can buy nappies and milk and such things. He even tried opening up a house shop so that I can keep myself occupied while he was at work during the day” P10

One of the participants reported how the surrounding community members encouraged her to start baking again and supported her by regularly placing orders. This helped relieve some of her financial strain. She stated:

“The community supported me well and some people would to say ‘Sarah, no one makes a doughnut like you’. From there on my business started again, and then people started buying from me again, and I made good money” P1

3.3 Entrepreneurship and education a strategy to empowerment

This theme presents the participants’ perceptions and opinions on factors that should be addressed towards promoting the development of self-employment programmes for women with ABI and disabilities.

Category one: A need for information and mentorship

This category explains the participants’ views on how the rehabilitation programme can be made more endearing for women with ABI by means of entrepreneurial skills training. A need was identified to gain more knowledge, skills, support and guidance on how to start small self-employment initiatives. A participant stated:

“There are difficult times, then I consider starting a small business ... then I think how do I begin?” P2

The participants reported that becoming self-employed is a viable solution to improve their current financial situation and it would also allow them to remain productive and improve functional and work skills. A participants stated:

“I need to understand how to start my own business properly, I need to have the basic foundation like a learnership course in venture creation, something like that” P4

Some participants reported that they believe that they would be able to start their own business, however they would require external support. Some participants stated:

“I would like support from another small business owner, just to get some insight to how to go about and how to run it and make it better” P7

“You know… people from other businesses can come around, to support or have small business workshops where they can maybe give guidance” P8

Category two: It is difficult to start entrepreneurial ventures without funds

In this category the study participants expressed their concerns about their limited knowledge on how to gain financial support to start a small business. Even though there is financial assistance available for small business start-ups, they were not aware of such resources for individuals with disabilities who want to become self-employed. A participant expressed her situation by stating:

“Every time I plan to do something to earn more money, but when it gets to that then the rent needs to be paid, electricity needs to be paid and there is always something. You cannot start something (own venture) because you need financial support” P2

Another participant stated that she is good with styling people’s hair and has the skills to work for herself. However, with limited funds she cannot afford the equipment and materials to start her own business. She stated:

“I’ve learnt now and have experienced the difficulty of not having enough money. Having your two hands and you have the skills ... but you need blow dryers and flat irons, some money for shampoos, conditioners and your hair chemicals and whatever you need to start off. Its things you need some money for” P8

Another participant became a street vendor and started making her own yogurt products. She reported her difficulties to financially sustain her business. She stated:

“The ingredients are not cheap, so in the yogurt there is coconut milk and it is organic. The funds are very important as some days there is no sales. If only I can get a financial push just to cover those days when sales are low so that the business don’t go completely bankrupt” P5

4 Discussion

The purpose of this study was to gain a deeper understanding of the experiences of women with ABI during their rehabilitation process, their resumption to work, and entrepreneurial skills development. The perceived barriers and enablers will be discussed.

4.1 Barriers

4.1.1 Communication oversights during rehabilitation

In theme one it became evident that most of the study participants perceived their rehabilitation process as a discouraging forecast to their future well-being. Individualised patient information, advice and follow-up are of significant importance for the recovery of people with acquired brain injury [26]. The participants did not feel confident enough to freely communicate their needs with the health team during their rehabilitation process. According to Ponsford [27], self-esteem often decline after ABI, and that is also a result in this study. A lack of knowledge about their health condition and how it might impact on their daily functioning exacerbated the participant’s fears and anxiety about their future well-being. Limited post-discharge guidance and follow-up influenced how some participants came to terms and adjusted to their new situation post-ABI. Thus, there is a contradiction between the study participants’ experiences and the notion stating that patient participation is a strategy that will facilitate a patient-centred approach, which in turn leads to patient empowerment [28].

4.1.2 Difficulty coping during return to work

The challenges some study participants experienced during their work reintegration process is reported in theme one. Even though client involvement as the primary decision makers and active recipients of services has long been recognised as a primary tenet in vocational rehabilitation [28] the majority of the participants were not actively involved in their RTW planning. According to Levack and Dean [29], the agency culture or specifically a team approach can positively influence a client’s achievement in obtaining a job. The participants reported having received minimal vocational counselling and inadequate RTW support post-ABI. The participants highlighted that low self-awareness after their ABI hindered their ability to self-monitor and employ self-regulating behaviours during task performance. According to Ownsworth [30], accurate self-appraisal of personal abilities following ABI contributes to motivation and the ability to set realistic employment goals. Cronin et al. [31] stated the performance of work is interdependent on the resources of the person, the workplace and contextual demands. Most of the study participants continued experiencing cognitive, physical, emotional and social difficulties upon their RTW. Soeker and Darries [32], found that post-injury sequelae of women with traumatic brain injury impacts on their ability to adapt to their pre-morbid worker identity and work roles. Similarly, the participants of this study experienced non-accommodative work environments that lead to premature job loss.

4.1.3 Diminished trust in the self

In theme two the study participants experienced a significant lack of perceived control, ambition and determination for vocational goal attainment. This consequently manifested a debilitating sense of well-being. In discovering a new identity after brain injury, individuals often experience a “loss of self” in three areas which include a decrease in self-knowledge, a loss of self in comparison to their pre-morbid self-image, as well as a loss of self-confidence [33]. For the participants in the current study difficulty relating to their previous worker identities and in pursuing vocational goals revealed a poor self-efficacy consequent to their injury. Having self-efficacy highlights one’s perceptions of his or her skills and abilities in successful respectable performances [34]. Ownsworth [30] advocated approaches that equally address metacognitive and contextual factors, especially regarding factors of self-efficacy towards occupational attainment.

4.1.4 The burdensome time gap between ABI and RTW

The reports of the study participants in theme two confirmed that the loss of a stable income significantly impacted on their quality of life and overall well-being. Satisfaction and happiness have been linked to periods in the life course when men and women attain expected levels of material goods and family life status [35]. The risks of poverty increasing disability conversely contributes to the increasing burden of disease in various communities, especially within the South African socio-economic context. Women with ABI and disabilities are at greater risk of unemployment as a result of the projected downward trend of job availability in the formal employment market in South Africa. This coincides with Matérne, Lundqvist and Strandberg [36] who stated that injury-related factors, occupational demands, available supports structures as well as the socio-political context significantly influence resumption to work for individuals with ABI. Soeker [37] emphasised that entrepreneurship can be a facilitator to productive work as it will allow individuals with brain injury and disabilities to establish their own income generating opportunities when formal jobs are inaccessible.

4.1.5 It is difficult to start entrepreneurial ventures without funds

In theme three study participants reported that a lack finance was one of their biggest challenges to pursue entrepreneurial initiatives. This coincides with studies that found that a lack of finance is one of the biggest barriers to self-employment ventures for people with disabilities [38]. The South African government and private enterprises have existing programmes and funds in place aimed at empowering women and those with disabilities. However, the participants in this study experienced lingering executive skills deficits and lacked the necessary technical knowledge and skills to pursue formal applications for financial assistance. Kitching [39] asserted that policy-makers need to consider inclusive methods of delivering advice and support to disabled entrepreneurs. Gamieldien and Van Niekerk [40] emphasised the importance of occupational therapists to facilitate the integration of their clients into supportive environments created by government that aids in establishing small and micro-enterprises for individuals with disabilities.

4.2 Enablers

4.2.1 A need for information and mentorship

In theme three the study participants voiced an innate desire to regain control of their lives, to remain productive and improve their work skills. The participants emphasised that self-employment and entrepreneurship is an empowering and relevant occupation to enhance their occupational performance and financial self-reliance. Van Hal et al. [41] posited that during vocational rehabilitation the process of empowerment is recognised as the belief that individuals should be able to choose and take charge of their own journey back to the work force. Thus, recommending vocational interventions that are unique to each individual’s needs, contexts and experiences. Some participants reported that they believe that they would be able to start their own business, however they would require external support. In order to implement entrepreneurship education, the following strategies have been empirically identified namely, training of the trainee on practical projects and simulate real experiences that are similar to daily trades [42]. Entrepreneurship education for individuals with disabilities needs to adopt the best possible form of individual tailoring [43]. Occupational therapists should adopt an eclectic approach in conjunction with various theoretical models and treatment modalities to enhance the occupational self-efficacy of individuals with brain injury [44]. Therefore, a holistic client-centred approach within the vocational rehabilitation context is essential towards redefining women with ABI’s experience of disablement in an employment market by means of entrepreneurship education and skills training [16].

4.2.2 Social support enhances occupational engagement

Theme two revealed that the social environment aided in the activity engagements of the study participants, which shows that a supportive and accessible environment enhances occupational participation. The study participants reported that the support from family and community motivated them to work towards gaining functional independence. The support from family offers significant value and benefits during the recovery process of the individual with brain injury [37]. The participants confirmed that encouragement and support from family and community to pursue small ventures improved their confidence, functional abilities as well as provided a sense of purpose and vocational direction. Informal family support plays a significant role in the lives of individuals with disabilities including the provision of financial or physical assistance during self-employment start-up efforts [38]. This affirms that as part of interventions to enhance the entrepreneurial skills of women with ABI, a strong social support network and the inclusion of family and significant others should be facilitated during such empowering intervention processes [37].

4.3 Limitations

A limitation of the study is that no other race other than Coloured 1 and White females took part in the semi-structured interviews. Data obtained from women with ABI from different race or cultures may have contributed to the depth of the content should there have been an equal representation in this regard.

5 Conclusion

The findings of this study suggest that women with ABI perceives their interaction with the health professionals’ post-injury as a barrier to a patient-centred rehabilitation approach. The findings also indicate that unmet individual needs, desires and preference to occupational engagement for women with ABI results in RTW challenges and premature job loss. Women with ABI continues to experience prolonged participation restrictions and a sense of disempowerment post-injury that causes financial hardship and decreased quality of life. The social environment is an enabler to activity participation as well as entrepreneurial engagement for women with ABI. Although entrepreneurship development is supported and embedded in South Africa’s legislature and policy guidelines on economic empowerment, a holistic occupation-based approach will aid in facilitating a process of entrepreneurial skills empowerment and occupational participation for women with ABI.

Footnotes

Acknowledgments

The authors wish to extend their appreciation to Tygerberg and Groote Schuur Hospital, the Occupational Therapy Departments, and Work Assessment Units; for their support and resources that assisted towards the meaningful outcome of this study. The authors would also like to thank the study participants for their disposition to share their experiences. The authors would like to thank the study participants for their contribution in the completion of the project.

Conflict of interest

The authors report no conflicts of interest.

Funding

The authors obtained funding from the National Research Funding (South Africa) in order to complete the study.

Coloured Race: The racial group termed coloured is defined as a person of mixed European (“black”) or Asian ancestry, as officially defined by the South African government from 1950 to 1991 [].

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