Facilitators and barriers to employment for people with physical disabilities: A cross-sectional study

Abstract

BACKGROUND:

There is increasing evidence that employment, or the lack thereof, affects an individual’s health. Consequently, employment provides people with physical disabilities (PWPD) with financial independence, enhances their well-being and self-worth, and facilitates a sense of purpose. People with physical disabilities often retain job skills and motivation to return to work after acquiring a disability. Their vocational rehabilitation and job accommodation needs likely differ from people with disabilities resulting from developmental, sensory, cognitive, and mental health conditions. To better target the needs of PWPD and improve vocational rehabilitation services, it is crucial to identify the modifiable factors that influence their employment outcomes.

OBJECTIVE:

This research aimed to examine systematically the client-, employer-, and context-related facilitators and barriers to employment experienced by PWPD.

METHODS:

We recruited to this cross-sectional study, PWPD from the Midwestern United States who returned to work after injury or illness. An online survey collected data on demographic characteristics and educational history; disability and functional status; supports, facilitators and barriers to employment; and job information and accommodations.

RESULTS:

347 working-age PWPD completed the survey; at the time of survey completion, 270 were working and 77 were not. People with physical disabilities who reported social support and encouragement at work were more likely to be working than respondents who did not. Negative attitudes of supervisors and colleagues, inaccessible work environments, and inflexible work schedules were barriers to employment. Important reasons for working included financial needs, a sense of purpose, and self-worth.

CONCLUSIONS:

Results provide insights into the importance of social supports in the work environment. Novel approaches are needed to develop supportive relationships with supervisors and coworkers.

Keywords

Rehabilitation vocational return to work work employment supported unemployment disabled persons

1 Introduction

Work is essential in ensuring economic well-being, autonomy, and additional benefits. For people with physical disabilities (PWPD), employment is critical to providing financial independence, access to housing, transportation, health insurance, and community participation of their choosing [1 –6]. People with physical disabilities retain job skills and motivation to return to work after acquiring a disability [1, 7]. There is increasing evidence that employment, or the lack thereof, affects an individual’s health [8]. Working after injury or disease onset helps PWPD improve their well-being, self-esteem, and life satisfaction; decreasing their risk of mental health problems and emotional distress [1]. Participation in work improves the health of PWPD and assists them to live a more productive life [7, 9].

Despite the importance of work, employment outcomes and work environments for PWPD are not favorable [10 –13]. Unemployment may reflect illness or disability status, high risk of being furloughed, and economic insecurity [14]. However, only 18.6% of unemployed individuals with disabilities received compensation or benefits when they were not working, even though more than half had filed for unemployment benefits [14]. The Brookings Institute reported that low-wage workers were more likely to encounter job losses during the COVID-19 pandemic than high-wage workers [15]. There is an urgent need to address employment inequities experienced by PWPD, including sub-minimum wages, which perpetuate structural inequities. A move away from sheltered work and sub-minimum wages is supported by Medicaid’s HCBS Settings Rule, which requires that people with disabilities have the same access to community-based employment as people without disabilities [16].

Federal and state governments and local agencies provide vocational rehabilitation services to support PWPD in employment and return to work (RTW). Vocational rehabilitation is a key component of the RTW process. Vocational rehabilitation services include counseling, evaluation of job demands, and determining the need for job accommodations. Vocational rehabilitation counselors assess needs for modifications to the work environment while considering an individual’s physical and cognitive abilities to enhance job performance. Job accommodations are an integral part of the vocational rehabilitation process and are mandated by the Americans with Disabilities Act [17]. Job accommodations, which are an adjustment or modification to how a job task is performed, can range from changes in work schedules or location to the use of assistive devices. Job accommodations are often provided at low or no cost to the employer. McNeal et al. reported that 51 percent of job accommodations cost nothing and 30 percent cost less than $500 [18].

People with physical disabilities often encounter complex challenges in obtaining and maintaining jobs that are related to their impairments. After sustaining injury or disease onset, PWPD may experience unpredictable recovery trajectories and require multiple employment supports to return to work. Due to their physical impairments, PWPD often require various job accommodations to attain successful employment outcomes. Their support needs may be quite distinct from those of people with cognitive, developmental, sensory, and mental health conditions [10]. However, this population often retains communicative and cognitive functions and are able to identify and communicate their accommodation needs. Previous studies have demonstrated that PWPD are often able to acquire work skills for competitive employment, advocate for reasonable accommodations, and adjust to diverse work environments [19]. Consequently, PWPD have the highest workforce participation and employment rates among people with intellectual, psychosocial, and neurological impairments [20]. Many employment studies do not distinguish type of impairment and combine all disability groups into a single category [21 –24]. To better target the distinctive needs of PWPD in the workplace and provide effective vocational rehabilitation services, it is crucial to identify the barriers and facilitators to employment experienced by PWPD.

Few studies have examined the influences on employment outcomes for PWPD, though some studies have identified personal and contextual influences on employment for people with diverse disabilities. Personal factors include functional skills and psychological resources [25, 26]. Employees with disabilities who encounter difficulties completing work tasks and schedules often benefit from flexibility in how they perform essential job responsibilities [27]. Employees’ fear of stigma and employment discrimination may limit their requests for job accommodations [23, 28]. Self-advocacy training and education about accommodations can facilitate employees’ understanding, requesting, and using accommodations [19, 23]. Contextual factors include job demands and environmental characteristics [19]. An unsupportive workplace culture and employers’ lack of knowledge or experience providing job accommodations create significant barriers to employment [19 , 29]. Coworker and supervisor support are critical influences on workplace participation for employees with disabilities [30]. Job accommodations reduce barriers and support employees’ productivity [19]. Finally, flexible policies regarding leave, health benefits, and disability payments support employment and job performance of individuals with disabilities [19, 23].

Although previous studies have identified personal and contextual factors to employment for people with a wide range of disabilities or specific impairments, few studies have investigated the influence of factors impacting employment outcomes among PWPD [31]. Most studies focused on a single impairment (e.g., traumatic brain injury, spina bifida, HIV/AIDS, cancers, stroke, and cerebral palsy) [2 , 32], collected data from relatively small samples [33], or used qualitative methods [29, 34]. Few studies have investigated comprehensively the influence of specific factors on RTW for people with PWPD. Importantly, we do not know how PWPD perceive the usefulness of employers’ support. Thus, the objective of this study was to examine the barriers, challenges and facilitators PWPD experience when regaining employment; therefore, we excluded participants who had not returned to work after injury or disease. This project aimed to:

Describe the motivations for work following onset of disability among PWPD with diverse etiologies, and

Identify the client-, employer-, and context-related facilitators and barriers to employment after injury or illness for those who had returned to work.

2 Methods

2.1 Research design

We used a cross-sectional design to obtain information from PWPD and their experiences receiving job accommodations and supports while employed. To ensure survey relevance, we used several resources to create questions and design the survey: (1) a survey created by the Office of Disability Employment Policy (ODEP) [35], (2) a questionnaire created by Hartke and Trierweiler [36], (3) the job accommodations scale created by Shaw, Kristman [37], (4) resources developed by the Job Accommodation Network [38], (5) a guide to recruiting, hiring and retaining people with disabilities [39], (6) the Disability Equality Index developed by Disability:IN and American Association of People with Disabilities (AAPD) [40], and (7) the 2017 Disability Employment Tracker created by National Organization on Disability [41]. We convened an advisory group composed of former vocational rehabilitation clients, long-term disability staff, employers of PWPD, independent living center representatives, and Illinois Division of Rehabilitation Services staff, to acquire input on survey design. To capture the important issues and factors associated with participants’ work experience after diseases or injury, we completed a systematic literature review of job accommodations [19].

We pilot tested the survey to ensure that questions were clear, concise, and familiar to participants. We conducted 40 semi-structured telephone interviews with PWPD and revised questions and survey organization based on participants’ responses during pilot testing of 118 survey questions. We stratified the pilot study respondents by employment duration – less than one year (n = 10), one to three years (n = 10), three to ten years (n = 10), and more than ten years (n = 10).

Pilot test recruitment focused on people who had received vocational rehabilitation services at the Shirley Ryan AbilityLab. Recruiting, consenting, and interviewing followed an Institutional Review Board (IRB)-approved protocol. Survey questions included demographic characteristics, education history, disability and functional information, supports and barriers to employment, job information, and job accommodations. Research team members recorded interviews with secure caller software and documented participant responses on a paper survey. The research team met weekly to review interviews and identify needed revisions, then entered telephone interview data into REDCap, a secure online application designed to support research surveys and data collection [42].

After pilot testing, we built the survey in REDCap and consulted with a biostatistician to review survey response options and data collection methods. We conducted structured cognitive interviews with five PWPD to enhance clarity of the survey. We invited PWPD to share their thought processes while answering the questions (think-out-loud approach) [43]. We identified potentially misleading and confusing questions when participants responded hesitantly, asked for clarification, or interpreted questions differently than we intended. We added definitions and examples to improve the clarity of survey questions. We revised the survey based on cognitive interview feedback for dissemination in the Midwest USA.

We designed the online survey before the COVID-19 pandemic and did not intend to measure the consequences of the COVID-19 pandemic on employment outcomes. Thus, we asked participants to report their work experience and work status right before the COVID-19 pandemic by including this statement: “The following questions focus on your employment experiences before the COVID-19 pandemic.” We collected participants’ experiences during the pandemic by inviting them to share consequences on the employment outcomes influenced by the pandemic and reported the findings in a previous manuscript [14].

We distributed the survey via REDCap [42] between October 2020 and March 2021. The first page provided instructions and a consent statement. The research was approved by the Institutional Review Board at Northwestern University (STU002080453).

2.2 Participants

Eligibility criteria for this analysis were: (1) aged over 18 years, (2) ability to speak and understand English, (3) a physical disability as the primary disability, and (4) returning to work after injury or illness onset. We defined a physical disability as a limitation of physical functioning, mobility, dexterity, or stamina, which may limit activities of daily living. Based on participants’ responses during pilot testing, we learned that many people with neurological injuries or conditions do not consider themselves as having a physical disability. To ensure our sample included people with neurological impairments, we established decision logic such that responses of “I don’t have a physical disability” would be followed by: “Have you ever had a brain injury, a neurological disorder or Multiple Sclerosis?” We included participants who affirmed neurological conditions despite denying a physical disability.

We sent letters and emails to clients who received vocational rehabilitation (VR) services from the Shirley Ryan AbilityLab, as well as others who satisfied qualifying criteria using the Shirley Ryan AbilityLab’s electronic medical records. Utilizing contacts from Shirley Ryan AbilityLab vocational rehabilitation department and electronic medical records, we had access to over 1,000 clients with up to 10 years’ experience after job placement. We used social media, mailings, an invitation via the Shirley Ryan AbilityLab patient portal, and consumer organizations to engage people in Illinois and surrounding states. We sent two to five reminder emails, though we were unable to send reminders to individuals who enrolled via social media.

A total of 549 potential participants were confirmed eligible and reported their work histories. After excluding 171 respondents who never returned to work or obtained employment after onset of disability and 31 respondents who only provided demographic information, 347 respondents met the eligibility criteria and provided employment data. To evaluate effects of missing data, we compared the missing participants and respondents included in the data analysis. There were no significant differences in demographic characteristics listed in Table 1 between these groups (missing: n = 31; respondents: n = 347).

Table 1
Sample characteristics: Currently working vs. not working

Currently Currently not

working working

(n = 270) n (%) (n = 77) n (%)

White race 200 (75) 58 (77)

Female 140 (52) 54 (72)

Age, mean (SD), years 47 (14) 51 (13)

Marital

Married or living with significant other 165 (61) 33 (43)

Single 81 (30) 31 (40)

Divorce or separate or widowed 23 (9) 13 (17)

Primary disorder

Neurological 136 (30) 33 (47)

Musculoskeletal 77 (52) 18 (26)

Other 44 (17) 19 (27)

Walks without assistance 168 (62) 40 (52)

Education

High school diploma/ GED or less 15 (6) 4 (5)

Associate degree, trade license, certificate 60 (22) 24 (31)

Bachelor’s degree 93 (34) 24 (31)

Master’s or doctoral degree 102 (38) 25 (33)

Facilitators

Positive feedback about my work performance 190 (79) 37 (66)

Support from my supervisor 188 (80) 32 (58)

Acceptance of my disability from coworkers 161 (77) 31 (72)

Emotional support 135 (58) 21 (41)

Used any job accommodation 129 (55) 29 (62)

Help with other life tasks outside of work 67 (27) 42 (68)

Parking privileges 66 (28) 14 (28)

Transportation assistance 32 (13) 25 (25)

Barriers

Job demands and workload 102 (41) 40 (68)

Negative attitudes of others at work 62 (33) 30 (63)

Work schedule 70 (28) 32 (53)

Workspace or environment 61 (24) 23 (39)

Safety in the workplace 57 (23) 13 (22)

Getting around your house, including 47 (19) 12 (21)

entering or exiting

	Currently	Currently not
White race	200 (75)	58 (77)
Female	140 (52)	54 (72)
Age, mean (SD), years	47 (14)	51 (13)
Marital
Married or living with significant other	165 (61)	33 (43)
Single	81 (30)	31 (40)
Divorce or separate or widowed	23 (9)	13 (17)
Primary disorder
Neurological	136 (30)	33 (47)
Musculoskeletal	77 (52)	18 (26)
Other	44 (17)	19 (27)
Walks without assistance	168 (62)	40 (52)
Education
High school diploma/ GED or less	15 (6)	4 (5)
Associate degree, trade license, certificate	60 (22)	24 (31)
Bachelor’s degree	93 (34)	24 (31)
Master’s or doctoral degree	102 (38)	25 (33)
Facilitators
Positive feedback about my work performance	190 (79)	37 (66)
Support from my supervisor	188 (80)	32 (58)
Acceptance of my disability from coworkers	161 (77)	31 (72)
Emotional support	135 (58)	21 (41)
Used any job accommodation	129 (55)	29 (62)
Help with other life tasks outside of work	67 (27)	42 (68)
Parking privileges	66 (28)	14 (28)
Transportation assistance	32 (13)	25 (25)
Barriers
Job demands and workload	102 (41)	40 (68)
Negative attitudes of others at work	62 (33)	30 (63)
Work schedule	70 (28)	32 (53)
Workspace or environment	61 (24)	23 (39)
Safety in the workplace	57 (23)	13 (22)
Getting around your house, including	47 (19)	12 (21)
entering or exiting

2.3 Data analysis

We summarized participants’ demographic and disability characteristics and employment status using means (standard deviations) for continuous variables and counts (proportions) for categorical and ordinal variables. To investigate whether client-, employer-, and context-related factors were associated with work status after injury or disease, we distinguished respondents who were working when they completed the survey from those with a work history who were not currently working. We excluded retired respondents from these analyses (n = 45). For Aim 2, we used bivariate logistic regression to evaluate the association of each exposure variable with participants’ current employment status (currently working vs. currently not working). We included all exposure variables with a bivariate association of p < .05 in the two subsequent multivariate logistic regression models. A 2-sided p-value<.05 denoted statistical significance, with no adjustment for multiple comparisons. We evaluated the magnitude of collinearity with variance inflation factors. We performed analyses using R statistical software [44].

To examine if job characteristics are associated with participants’ current work status, we adopted two indicators, job-required training and physical demands, to represent the job characteristics. We used the Specific Vocational Preparation (SVP), a Worker Characteristics Categorization system, to estimate the amount of training required for workers to obtain the necessary techniques, knowledge, and facilities to perform work-related tasks [45]. The rating scale ranges from 1 (short demonstration only) to 9 (over 10 years) [45]. We also used strength level to represent the physical demands that are needed for typical performance in a specific job. Strength level (from sedentary, light, medium, heavy, to very heavy) was calculated based on the weight and duration related to lifting, carrying, and standing [46].

3 Results

3.1 Sample characteristics

Table 1 displays the demographic characteristics of the included participants, distinguishing those who were working when they responded to the survey: currently working (n = 270), and those with a work history after illness or injury but not currently working (n = 77). We excluded participants who had not returned to work since they acquired the disability because they may not have experienced barriers, challenges, or help in the workplace when returning to work. Compared to the U.S. population, the disability sample is similar in terms of sex (female- National: 52% vs. our sample: 56%) but had higher educational attainment (bachelor’s degree or higher educational achievement National: 16% vs. 70%) and fewer minority respondents (White National: 66% vs. 74%) [47, 48].

In the currently working group, more than half were White (75%; n = 200), female (52%, n = 140), walking without assistance (62%; n = 168), and either married or living with a significant other (61%; n = 165). The average age was 47 years and musculoskeletal disorders were the most common condition (52%; n = 77). Education attainment included associate (22%), bachelor’s (34%), and a master’s or doctoral degree (38%). The most frequently reported facilitators for the currently working group were support of supervisor (80%, n = 188), positive feedback about work performance (79%, n = 190), and coworkers’ acceptance of disability (77%, n = 161).

For the currently not working group, more than half were White (77%; n = 58), female (72%; n = 54), and walking without assistance (52%; n = 40). The average age was 50 years and neurological disorders were the most common condition (47%; n = 33). Like the currently working group, education level was evenly split between associate (31%), bachelor’s (31%), and a master’s or doctoral degree (33%). The most frequently selected facilitators were acceptance by coworkers (72%, n = 31), help with other life tasks outside of work (68%, n = 42), and positive feedback about work performance (66%, n = 37).

Both groups most frequently reported the following barriers: job demands and workload (currently working: 41%; n = 102 and currently not working: 68%; n = 40) and negative attitudes of others (currently working: 33%; n = 62 and currently not working: 63%; n = 30). The currently not-working group was more likely to report these barriers than the working group.

3.2 Aim 1: Motivation for working

Currently working participants rated eight reasons in terms of importance for keeping a job. The rating scale ranged from “not at all important” to “very important.” We report in the following results the percentage of participants who responded “very important”. Financial-related issues, such as having financial security to support myself or my family (84% as “very important”), making enough money to pay my bills (81%), and keeping my benefits (81%), were the most frequent reasons for working. Motives related to a sense of purpose and self-worth were also important, including being confident in my job skills (78%) and feeling like I play a critical role in my work organization (66%). Social relationships were also a common motivator for work, including having good communication with my supervisor (65%) and having someone at work that I can relate to or confide in (47%). Having opportunities for advancement was important to 46% of respondents.

3.3 Aim 2: Client-, employer-, and context-related facilitators and barriers to employment

In the bivariate logistic regression, younger age (OR [95% confidence interval] = 1.02 [1.002, 1.04], p = .03) and male sex (2.33 [1.33, 4.08], p = .003) were associated with higher odds of working. Job characteristics (including job-required training and physical job demands), education, marital status, and race did not distinguish the currently working and not working groups (Table 2). Facilitators associated with current employment included receiving support from supervisors (2.82 [1.51, 5.24], p = .001), emotional support (1.99 [1.07, 3.68], p = .03), and positive feedback about work performance (1.88 [1.00, 3.53], p = .051). Respondents who received transportation assistance (0.47 [0.23, 0.96], p = .04) and help with life tasks outside of work (0.18 [0.10, 0.33], p < .001) were less likely to be employed than those who did not receive assistance. These results suggest that participants who experienced unemployment had lower levels of function and had more accommodation needs than those who were working.

Table 2
Currently working vs not working group comparisons: Bivariate logistic regression results

OR (95% CI) p Value

Age, mean (SD), years 1.02 (1.002, 1.04) .03

Male 2.33(1.33, 4.08) .003

White race 0.87(0.48, 1.61) .67

Marital status

Single Reference

Married or living with significant other 1.91 (1.10, 3.34) .02

Divorce/separate/widowed 0.68 (0.31, 1.50) .34

Primary disorder

Musculoskeletal Reference

Neurological 1.04 (0.55, 1.97) .91

Other 0.56 (0.29, 1.09) .09

Education

High school diploma/GED or less Reference

Associate degree, trade license, certificate 0.67 (0.20, 2.21) .51

Bachelor’s degree 1.03 (0.31, 3.40) .96

Master’s or doctoral degree 1.09 (0.33, 3.56) .89

Walking without any assistance 1.52 (0.91, 2.54) .11

Job characteristics

Specific Vocational Preparation (SVP) ^† 1.1 (0.95,1.36) .16

Strength §

Medium, heavy, very heavy Reference

Light 1.1 (0.33, 3.58) .89

Sedentary 0.6 (0.20, 1.93) .40

Facilitators

Support from my supervisor 2.82 (1.51, 5.24) .001

Emotional support 1.99 (1.07, 3.68) .03

Positive feedback about my work performance 1.88 (1.00, 3.53) .051

Acceptance of my disability from coworkers 1.27(0.61, 2.66) .52

Parking privileges 1.01(0.51, 1.98) .98

Job accommodations 0.76 (0.40, 1.45) .41

Transportation assistance 0.47(0.23, 0.96) .04

Help with other life tasks outside of work 0.18 (0.10, 0.33) <.001

Barriers

Getting to/from work 1.06 (0.95, 1.19) .27

Safety in the workplace 1.03 (0.52, 2.04) .93

Getting around your house 0.88 (0.43, 1.79) .72

Unstable living situation 0.69 (0.29, 1.62) .39

Workspace/environment 0.49 (0.27, 0.89) .02

Negative attitudes of others 0.29 (0.15, 0.57) <.001

Work schedule 0.35 (0.20, 0.63) <.001

Job demands and workload 0.33 (0.18, 0.60) <.001

	OR (95% CI)	p Value
Age, mean (SD), years	1.02 (1.002, 1.04)	.03
Male	2.33(1.33, 4.08)	.003
White race	0.87(0.48, 1.61)	.67
Marital status
Single	Reference
Married or living with significant other	1.91 (1.10, 3.34)	.02
Divorce/separate/widowed	0.68 (0.31, 1.50)	.34
Primary disorder
Musculoskeletal	Reference
Neurological	1.04 (0.55, 1.97)	.91
Other	0.56 (0.29, 1.09)	.09
Education
High school diploma/GED or less	Reference
Associate degree, trade license, certificate	0.67 (0.20, 2.21)	.51
Bachelor’s degree	1.03 (0.31, 3.40)	.96
Master’s or doctoral degree	1.09 (0.33, 3.56)	.89
Walking without any assistance	1.52 (0.91, 2.54)	.11
Job characteristics
Specific Vocational Preparation (SVP) ^†	1.1 (0.95,1.36)	.16
Strength §
Medium, heavy, very heavy	Reference
Light	1.1 (0.33, 3.58)	.89
Sedentary	0.6 (0.20, 1.93)	.40
Facilitators
Support from my supervisor	2.82 (1.51, 5.24)	.001
Emotional support	1.99 (1.07, 3.68)	.03
Positive feedback about my work performance	1.88 (1.00, 3.53)	.051
Acceptance of my disability from coworkers	1.27(0.61, 2.66)	.52
Parking privileges	1.01(0.51, 1.98)	.98
Job accommodations	0.76 (0.40, 1.45)	.41
Transportation assistance	0.47(0.23, 0.96)	.04
Help with other life tasks outside of work	0.18 (0.10, 0.33)	<.001
Barriers
Getting to/from work	1.06 (0.95, 1.19)	.27
Safety in the workplace	1.03 (0.52, 2.04)	.93
Getting around your house	0.88 (0.43, 1.79)	.72
Unstable living situation	0.69 (0.29, 1.62)	.39
Workspace/environment	0.49 (0.27, 0.89)	.02
Negative attitudes of others	0.29 (0.15, 0.57)	<.001
Work schedule	0.35 (0.20, 0.63)	<.001
Job demands and workload	0.33 (0.18, 0.60)	<.001

Note. ^†Specific Vocational Preparation (SVP), a type of Worker Characteristics information, is the amount of training time for typical workers to learn the needed techniques and information to perform adequately in the specific job-worker situation. The rating ranges from 1 (short demonstration only) to 9 (over 10 years) (45). §Strength level, a job characteristics on physical demands, is calculated based on the weight and duration related to lifting, carrying, and standing (46).

Individuals who regarded the environment (0.49 [0.27, 0.89], p = .02), negative attitudes (0.29 [0.15, 0.57], p < .001), work schedule (0.35 [0.20, 0.63], p < .001), and job demands and workload (0.33 [0.18, 0.60], p < .001) as obstacles, had a lower probability of current employment in comparison to those who did not perceive these factors as obstacles. Finally, we examined to what extent facilitators of current employment distinguished the currently working vs. not working groups using multivariate logistic regression, adjusting for age and sex. Currently working respondents were more likely to receive emotional support (5.38 [2.02, 14.35], p < .001) and less likely to receive help with life tasks outside of work (0.09 [0.04, 0.24], p < .001) than respondents who were not working (Table 3). A second multivariate logistic regression examined the influence of barriers, after adjusting for age and sex. Only negative attitudes of others (0.41 [0.18, 0.94], p = .04) distinguished the groups such that the currently working group reported fewer negative attitudes than the not working group (Table 3). Collinearity was not detected as defined by a variance inflation factor <10.

Table 3

Facilitators and barriers to current employment: Multivariate Results

	Facilitators model		Barriers model
	OR (95% CI)	p Value	OR (95% CI)	p Value
Age, mean (SD), years	0.97 (0.94, 0.99)	.02	0.95 (0.93,0.98)	.002
Male	3.44 (1.45, 8.17)	.005	3.17 (1.30,7.74)	.01
Facilitators
Support from my supervisor	1.27 (0.50, 3.22)	.62
Emotional support	5.38 (2.02, 14.35)	<.001
Positive feedback about my work performance
Acceptance of my disability from coworkers
Parking privileges
Job accommodations
Transportation assistance	0.74 (0.27, 2.00)	.55
Help with other life tasks outside of work	0.09 (0.04, 0.24)	<.001
Barriers
Getting to/from work
Safety in the workplace
Getting around your house
Unstable living situation
Workspace/environment			0.73(0.29, 1.82)	.50
Negative attitudes of others at work			0.41(0.18, 0.94)	.04
Work schedule			0.87(0.36, 2.12)	.76
Job demands and workload			0.54(0.22, 1.32)	.18

4 Discussion

4.1 Key findings of this research

Although numerous studies explore employment for people with disabilities in general, this study focuses on PWPD specifically. The study provides a comprehensive view of the personal and contextual factors related to employment for PWPD. First, we found that financial issues, a sense of purpose, and self-worth were important reasons for PWPD to return to work. The results align with Gustafsson’s [34] qualitative research, which reported that feeling like a valued worker and having a sense of social belonging motivate people with disabilities to join the workforce [34]. Second, we found that a positive work environment and family support are the primary facilitators of return to work after disability. We found that PWPD who are married or living with significant others are more likely to be employed than people who are not married. Previous research on people with intellectual disabilities and general disabilities also found that a well-designed work environment and support from family and co-workers are critical for employment success [23, 49].

Third, negative attitudes and inaccessible work environments were significant barriers. This finding is consistent with research on the work experience of individuals with brain-based disabilities who found that negative attitudes of employers and colleagues are major challenges in returning to work [50]. People with general disabilities also report that feeling “invisible” in the workplace affects the experience of returning to work [51]. Inaccessible work environments stand out as a major challenge experienced by PWPD. Finally, factors that reflect lower daily functioning and more accommodation needs, such as receiving transportation assistance and help with other life tasks outside of work, were associated with reduced likelihood of working. Previous studies on non-physical disabilities did not report similar findings on the negative relations between accommodations and work outcomes. This result may be specific to the population of PWPD in this sample.

Strengths of this study were the inclusion of contextual factors of employment and modifiable facilitators and barriers that vocational rehabilitation counselors may consider when helping PWPD obtain employment. This study also found that social support was the most significant facilitator of employment for PWPD. Consistent with the findings of Donker-Cools et al. on the brain injury population [34], creating an inclusive and positive work environment was the most effective and cost-free accommodation that enabled PWPD to maintain employment after disability due to disease or after injury [32].

4.2 Attitudes of supervisors and coworkers are the key to employment after injury or illness

This study found that negative attitudes of coworkers were a major barrier to employment for PWPD. These results are consistent with published findings that employees’ fears of negative attitudes at workplace (such as stigma and employment discrimination) are barriers to disclosure of their disability and accommodation needs [28, 52]. More important than avoiding stigma may be a sense of acceptance and feeling valued by coworkers [24 , 53]. Our study also found that positive attitudes of others both at home and in the workplace were important factors in employment. Bainbridge and Fujimoto reported that empathy and positive employer attitudes were associated with favorable employment outcomes [54]. Dong et al. also showed that workplace support is associated with the likelihood of receiving job accommodations and job satisfaction among PWPD [55].

4.3 Social support serves as the most significant facilitator to employment for PWPD

Respondents identified contextual supports as a key issue for employment. Support from supervisors, positive feedback, acceptance of their disability, and emotional support were strong facilitators of employment. These findings are consistent with prior disability employment research [36, 56]. Frank [56] that reported support from co-workers is crucial in the return-to-work process. Hartke et al. [36] noted in a post-stroke sample that a positive and inviting work environment is important to maintaining employment. Employees with disabilities have a strong desire for organizational support as part of their workplace culture [57]. These contextual supports have no monetary cost for employers but are critical factors for employment of PWPD. This contextual factor deserves more research attention given its importance in employment outcomes.

4.4 Potential impacts of the COVID-19 pandemic on employment for PWPD

The COVID-19 pandemic complicated investigation of the motivators, barriers, and facilitators of employment. For example, Lake and Maidment [58] reported that PWPD required additional environmental adjustments and needed greater flexibility in choosing workplace and work patterns during the pandemic [58]. We addressed this disruption in our study by assessing the effects of the pandemic and perspectives and experience among PWPD of how the pandemic affected their employment or intention to work [14]. For the current study, we reported work experience and work status of PWPD before the pandemic. Thus, our study findings are applicable to pre-pandemic situations and are not specific for employment outcomes during the pandemic. The COVID-19 pandemic effects on employment of PWPD deserves additional investigation.

4.5 Study limitations

The study findings provide useful information for clinicians, employers, and PWPD to understand the facilitators and barriers to employment; however, there are limitations to this study. First, we were not able to investigate whether there were differences between groups in motivations for work because we only asked questions regarding reasons for working when participants responded they were currently working. Although the survey design is reasonable, as people who were not working may not have strong motivation to work, we could not evaluate motivations for employment in the regression analysis. We excluded participants who had not returned to work since acquiring their disability because they may not have experienced barriers, challenges, or supports in the workplace when returning to work. Thus, the results do not reflect the experiences of a portion of PWPD who tried to return to work after disability but did not. Second, the sample is small and respondents resided primarily in the Midwestern United States, were predominantly white, English-speaking, attained higher education, and had internet access, limiting the generalizability of the findings. Our results showed that participants’ primary disorder might influence their work status; however, the differences were not statistically significant (Table 2). A larger sample is needed to increase the statistical power of the analysis. The respondents were recruited from the electronic medical records list at Shirley Ryan AbilityLab and from former clients at Shirley Ryan AbilityLab VR services, and so the survey results may reflect the outcomes of VR services. Replication with a larger, nationally representative sample with rigorous stratification by geography, industry, and job demands is needed to generalize findings with confidence. The representativeness of data may also have been affected by prospective participants’ limited Internet access to the web-based survey. The completion rate was 74.6% and there were no significant differences in the demographic characteristics of respondents who completed the survey versus those who did not, decreasing the length and time to complete the survey may have increased the completion rate. Another study limitation resulted from asking respondents to recall a time before the COVID-19 pandemic, potentially leading to recall bias. Lastly, the findings reflect retrospective self-report data. Employees with disabilities provided a critical perspective on the barriers and facilitators to their employment experiences; however, retrospective self-report methods are subject to recall and response bias. Future studies should triangulate these survey methods with multiple stakeholder perspectives or other forms of data collection.

5 Conclusions

The findings provide new information that informs our understanding of person-, employer-, and contextual-related facilitators and barriers to employment of PWPD. Results provide valuable insights into the emotional and social supports required for employment. Previous studies have focused on physical demands that facilitate job performance; however, this study demonstrated how important it is for supervisors and coworkers to provide social support to PWPD. Support from coworkers, as well as from peers, family, and friends is a strong factor in employment success of PWPD. Novel approaches to developing supportive relationships with supervisors and coworkers are needed.

Ethical approval

The research was approved by the Institutional Review Board at Northwestern University (STU002080453). This study was performed in line with the principles of the Declaration of Helsinki.

Informed consent

Online informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

We appreciate the efforts of the participants who shared their experiences.

Funding

This study was funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) (Grant Number: 90RTEM0001). Dr. Allen W. Heinemann is the grant receiver.

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	Currently	Currently not
	working	working
	(n = 270) n (%)	(n = 77) n (%)
White race	200 (75)	58 (77)
Female	140 (52)	54 (72)
Age, mean (SD), years	47 (14)	51 (13)
Marital
Married or living with significant other	165 (61)	33 (43)
Single	81 (30)	31 (40)
Divorce or separate or widowed	23 (9)	13 (17)
Primary disorder
Neurological	136 (30)	33 (47)
Musculoskeletal	77 (52)	18 (26)
Other	44 (17)	19 (27)
Walks without assistance	168 (62)	40 (52)
Education
High school diploma/ GED or less	15 (6)	4 (5)
Associate degree, trade license, certificate	60 (22)	24 (31)
Bachelor’s degree	93 (34)	24 (31)
Master’s or doctoral degree	102 (38)	25 (33)
Facilitators
Positive feedback about my work performance	190 (79)	37 (66)
Support from my supervisor	188 (80)	32 (58)
Acceptance of my disability from coworkers	161 (77)	31 (72)
Emotional support	135 (58)	21 (41)
Used any job accommodation	129 (55)	29 (62)
Help with other life tasks outside of work	67 (27)	42 (68)
Parking privileges	66 (28)	14 (28)
Transportation assistance	32 (13)	25 (25)
Barriers
Job demands and workload	102 (41)	40 (68)
Negative attitudes of others at work	62 (33)	30 (63)
Work schedule	70 (28)	32 (53)
Workspace or environment	61 (24)	23 (39)
Safety in the workplace	57 (23)	13 (22)
Getting around your house, including	47 (19)	12 (21)
entering or exiting