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Promoting employment among people with disabilities: Challenges and solutions

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This article focuses on difficulties that people with disabilities and reduced work capacity experience in employment and social participation, and on their rehabilitation goals, in order to make recommendations for policy and social and vocational rehabilitation service provision. A semi-structured interview procedure, which included the World Health Organization Disability Assessment Schedule 2.0, was used to conduct initial needs assessments with 85 persons in Estonia. Quantitative and qualitative data were gathered and analysed using descriptive statistics and thematic analysis. Results revealed that participants experienced multiple difficulties, which they mostly ascribed to unstable health conditions, that limited their abilities to participate in employment and social activities. A large number of participants also identified themselves as unemployed for health reasons and linked their rehabilitation goals to health restoration rather than becoming employed. Difficulties such as lack of work skills, unsuitable work tempo, mobility limitations, and emotional problems were also mentioned. To support people with disabilities in obtaining and maintaining employment, services must correspond to the persons´needpersons´need; and comprehensive, person-centred rehabilitation assessment, service planning, and budgeting mechanisms are needed. Supportive legislation, flexibility in service provision, and the availability of needs-based rehabilitation and other services, including lifelong learning opportunities, are also necessary to help people learn new work skills.
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PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
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Social Work & Social Sciences Review 18(1) pp.31-51
Promoting employment among people
with disabilities: Challenges and solutions
Karin Hanga1, Diana M. DiNitto2, and Jean Pierre Wilken3
Abstract: This article focuses on difficulties that people with disabilities and reduced work capacity
experience in employment and social participation, and on their rehabilitation goals, in order to
make recommendations for policy and social and vocational rehabilitation service provision. A semi-
structured interview procedure, which included the World Health Organization Disability Assessment
Schedule 2.0, was used to conduct initial needs assessments with 85 persons in Estonia. Quantitative
and qualitative data were gathered and analysed using descriptive statistics and thematic analysis.
Results revealed that participants experienced multiple difficulties, which they mostly ascribed
to unstable health conditions, that limited their abilities to participate in employment and social
activities. A large number of participants also identified themselves as unemployed for health reasons
and linked their rehabilitation goals to health restoration rather than becoming employed. Difficulties
such as lack of work skills, unsuitable work tempo, mobility limitations, and emotional problems
were also mentioned. To support people with disabilities in obtaining and maintaining employment,
services must correspond to the persons´ need; and comprehensive, person-centred rehabilitation
assessment, service planning, and budgeting mechanisms are needed. Supportive legislation, flexibility
in service provision, and the availability of needs-based rehabilitation and other services, including
lifelong learning opportunities, are also necessary to help people learn new work skills.
Keywords: persons with disabilities and reduced work capacity; social rehabilitation service;
vocational rehabilitation service; employment; WHODAS 2.0; personal choice; Estonia
1. Executive, Rehabilitation Competence Center, Astangu Vocational Rehabilitation Center, Doctoral
Student, Social Work Institute, Tallinn University
2. Cullen Trust Centennial Professor in Alcohol Studies and Education, University Distinguished
Teaching Professor, University of Texas at Austin
3. Professor, Research Centre for Social Innovation, HU Utrecht University of Applied Sciences, the
Netherlands; Visiting Professor Social Work Institute, Tallinn University
Address for correspondence: Karin Hanga, Allika 8, Kiili alev, Kiili vald, 75401 Harjumaa, Estonia.
karin.hanga@gmail.com
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
32
Introduction
Strong evidence shows that work is generally good for physical and mental health and
well-being (Wadell and Burton, 2006). Employment is the most important means
of obtaining adequate economic resources, which are essential for material well-
being and full participation in society (OECD, 2007). Work also meets important
psychosocial needs in societies where employment is the norm and work is central
to individual identity, social roles, and social status. Conversely, unemployment is
generally associated with poorer health (such as higher mortality, poorer general
health, long-standing illness) and mental health (such as psychological distress,
psychological/psychiatric morbidity), resulting in higher medical consultation,
medication consumption, and hospital admission rates (Wadell et al., 2007; OECD,
2009a).
Despite work’s importance for mental, physical, and material well-being, many
people with disabilities continue to face multiple barriers in obtaining or returning
to work (OECD, 2003; OECD, 2009b). This study aims to improve knowledge about
the situation of working age persons with disabilities and/or reduced work capacity
and their needs related to entering or re-entering the labour market. In particular,
this study focuses on understanding the barriers people with disabilities experience
in the workplace and in social participation, as well as their personal choices for
the rehabilitation process:
We address the following questions:
1. What difficulties do people with disabilities or reduced work capacity experience
in participating in employment and in society?
2. What rehabilitation goals do people with disabilities who are of working age
set for themselves?
3. What are the implications for improving policies and social and/or vocational
rehabilitation services that will increase the employment of people with
disabilities?
We begin by presenting an overview of the disability and rehabilitation context
in Estonia and parallels with other countries followed by the research methods used
in our study in Estonia and study results that address these questions. We conclude
by stressing the implications for designing policies and customizing social and
vocational rehabilitation services in order to increase employment, work capacity,
and societal participation for people with disabilities in Estonia and elsewhere.
Overview of the Estonian context and international parallels
Countries around the world are facing increasing combinations of social,
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
33
demographic, and economic challenges (OECD, 2009; OECD, 2012; OECD, 2014).
These challenges include, among others, increasing numbers of persons with chronic
health and mental health problems that affect their ability to work (WHO 2011).
For example, in Estonian, which has a population of 1.3 million, the number of
persons with disabilities rose by 29% from 97140 in 2004 to 137710 in 2014. The
number of persons receiving work incapacity pensions in Estonia has grown even
faster, from 55480 in 2004 to 103 262 in 2013, an increase of 46% (Statistics of
Estonia, 2014). The share of disability benefit recipients in Estonia’s working age
population is third highest among the OECD countries and is nearly double the
OECD average; in addition, the growth rate in the number of disability benefit
recipients over the last five years was the highest of OECD countries (OECD, 2014).
As in many other countries, growth in the number of persons receiving disability
pensions in Estonia is due not only to population ageing but also to conditions
such as increase in the statutory pension age, increased unemployment during the
years of economic recession, increased awareness of disabling conditions, improved
diagnostic procedures, and increased rates of serious chronic diseases such as
diabetes, cardiovascular diseases, cancers, and various psychiatric disorders, which
are the main causes of disability (Masso and Pedastsaar, 2006; Ministry of Social
Affairs, 2011).
In every country, people with disabilities have much lower employment rates
than the general population, leading to poverty or low income and reliance on
permanent disability benefits and a lower quality of life (Ministry of Social Affairs
of Estonia, 2009; Bloch & Prins, 2000; WHO, 2011). At the same time, many
countries, including Estonia, face workforce shortages (particularly in some regions
and especially for skilled jobs) and a considerable rise in public expenditures for
disability benefits and work incapacity pensions, which threaten the sustainability
of states’ social and financial systems (OECD, 2012; Praxis, 2011; Saar Poll, 2013).
People with disabilities are too often overlooked as individuals who can make
meaningful contributions to the workforce and to their communities.
Responding to disability and permanent work incapacity through
rehabilitation services
The notion of disability is defined in many different ways. Many countries have
adopted the United Nations Convention on the Rights of Persons with Disabilities
in 2006, and along with it, the convention’s definition of disability. According to
this definition ‘persons with disabilities include those who have long-term physical,
mental, intellectual or sensory impairments which in interaction with various
barriers may hinder their full and effective participation in society on an equal basis
with others’ (UN Enables, 2014).
To understand Estonia’s current system for responding to disability, it is necessary
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
34
to define two concepts in parallel use: disability and permanent incapacity for
work. Similar to the United Nations Convention, disability is defined as a ‘loss of
or an abnormality in an anatomical, physiological, or mental structure or function
of a person, which in conjunction with different relational and environmental
restrictions, prevents participation in social life on an equal basis with others’ (Social
Benefits for Disabled Persons Act, 2014). In addition to health problems, disability
assessment involves inquiries about a person’s social and environmental aspects of
functioning (in addition to health problems). Disability is determined by degree –
moderate, severe, or profound. Those determined to have a disability are entitled
to receive government nanced disability benefits, which aim to compensate for
the additional costs arising from disability (Estonian Social Insurance Board, 2014).
Permanent work incapacity is determined only for those aged 16 to 63 and is
primarily determined on the basis of a person’s health (social and environmental
aspects are considered only to a limited degree in specific cases). Those who have
permanent work incapacity at 40% or higher are entitled to receive a government-
financed incapacity pension, which aims to compensate for the loss of income from
work (State Pensions Insurance Act, 2014).
One way to provide support for persons with disabilities is rehabilitation. In
Estonia, the rehabilitation service is one of the core social services targeted to helping
people with disabilities improve independent functioning, social integration, and
entry into and stay in employment (Social Welfare Act, 2014). Social rehabilitation
includes rehabilitation needs assessment and planning, and counselling by various
specialists (social workers, occupational therapists, physiotherapists, psychologists,
speech therapists and special pedagogues). However, Estonia’s Social Welfare Act
sets limits for utilisation of each service—both financial limits per person for every
calendar year and limits on the amount of service a person can receive (e.g., 5 or 15
hours of a service per person). In addition, the social rehabilitation service does not
cover medical rehabilitation (medical services or interventions), which is nanced by
the Health Insurance Fund as medical services; labour market services (vocational
rehabilitation), a new service that will be financed by the Unemployment Fund
beginning in 2016; or other social services (home services, personal assistant and
support person services), which are the responsibility of local municipalities.
The need for change
Both national and international studies have identified serious shortcomings in
Estonian’s system for addressing disability and work incapacity and confirm the
need for change (Veldre et al., 2012; Radziwill & Singh, 2012). The current system
is neither economical nor sustainable. Incapacity pensions, disability benefits, and
certain services have been criticized for promoting passiveness among recipients.
The National Audit Office (2010) notes that in addition to monetary support,
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
35
people should be offered rehabilitation and other services, but these services are
fragmented, not available to everyone due to problems such as long waiting lists,
inefficient use of finances, and bureaucracy. These situations are not uncommon in
other countries (OECD, 2009).
OECD (2012) points out that rather than being an integrated system, Estonia’s
rehabilitation services are fragmented across the social, health, and labour market
sectors, and the help provided does not support the objective of entering the labour
force or returning to work. The National Audit Office (2008) and Saar Poll (2009)
also confirm that although rehabilitation services in Estonia are defined as social
services, the content of the service is strongly inclined towards medical procedures
(the main social service rendered was physiotherapy). Although rehabilitation
services may include various types of counselling, there is lack of purposeful,
complex interventions that would bring positive change in a person’s life (Astangu
Vocational Rehabilitation Centre, 2012). The Ministry of Social Affairs (2014)
confirms that only 16% of working age persons receiving rehabilitation services got
the help needed to access employment.
The OECD (2012) points to the urgent need to consider structural disability system
reform by shifting to employment-oriented measures that will reduce inflows into
the long-term incapacity-of-work pension system and move persons with partial
work capacity into productive employment.
In 2012, the Estonian government launched its biggest social reform in 15 years
connected with determining working capacity. Key reform priorities are: moving
from disability assessment to work-capacity assessment; a stronger focus on
individual responsibilities; improved cooperation across agencies to deliver effective
employment support; and responsibilities for employers. The reform includes
providing services that individuals need to gain employment, including vocational
rehabilitation as a new Labour Market Board service and restructuring the social
rehabilitation system to improve its efficiency (Parliament of Estonia, 2014a, b). Our
study provides valuable insights for designing these services and attuning them
to the wishes and needs of people with disabilities – insights that may be equally
important for other countries.
Study framework
The framework for this study includes the biopsychosocial approach to rehabilitation
as exemplified by the International Classification of Functioning, Disability and
Health (ICF) and an emphasis on client choice (Peterson, 2005; Lakhan, 2006).
ICF is one of the most comprehensive, integrative, and well-known approaches
for conceptualizing and classifying personal health, functioning, disability,
environmental barriers, and facilitators; collaborating with the person being assessed
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
36
to determine these factors; targeting interventions; and evaluating treatment efficacy
(WHO, 2001; Taylor & Geyh, 2012; Stucki et al., 2007). Using this approach,
rehabilitation is an all-inclusive process of facilitating entry or return to participation,
to the extent possible, in every aspect of normal life, including employment and
recreational activities.
Personal choice is also a key rehabilitation principle and a basic value in
psychosocial rehabilitation. When rehabilitation clients have choices and are able
to make decisions about their rehabilitation process, they are more motivated to set
goals and work actively towards realizing these goals (Wilken, 2005; Crowe et al.,
2012). Anthony and colleagues (2002) add that unless clients set their own goals,
there is no real direction for steering clients’ development.
Study design
The research design involved a pilot study using a semi-structured interview
procedure to conduct initial rehabilitation needs assessments of individuals
applying to the Estonian Social Rehabilitation Service. Four rehabilitation specialists
conducted face-to-face assessment interviews from September 2012 to March 2013.
Sampling
All study participants had applied for a determination of their disability or incapacity
for work status or for rehabilitation services at the Pension Departments at the three
largest cities in Estonia. To be included in the study, each applicant had to speak
Estonian, be at least 18 years old, and be working or at risk of dropping out of the
labour market due to a disability or health problem or not working with a long-term
goal of returning to work. Those who agreed to participate gave written informed
consent including use of their personal data for study purposes only. The first 101
persons (85 of them were of working age and 16 in retirement age) who applied for
disability and/or incapacity for work and/or social rehabilitation services during
the data collection periods and agreed to participate formed the study sample.
The sampling method can thus be described as opportunity sampling whereby
all consenting applicants were included in the sample. The sampling method was
chosen based on considerations of ease of access to the target group and economy,
and was regarded as appropriate given the pilot nature of the study. Eighteen other
applicants choose not participate due to lack of interest in the study, lack of time,
poor health, or because they did not speak Estonian. This article focuses on the 85
working-age participants.
The study’s limitations should be acknowledged, including a relatively small
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
37
sample size and the exclusion of those who could only have participated in Russian
or another language.
Assessment instrument
The initial rehabilitation needs assessment instrument included both closed- and
open-ended items and consisted of four parts. Part one contained questions about
the individual’s personal data (gender, age, disability, current life situation, marital
status, living situation, educational qualifications, employment status, leisure time
activities). Part two inquired about help the person had previously received or was
currently receiving (social services, health care services, employment services, or
services from a disability union, church) and how that help influenced functioning.
Part three was the 36-item interviewer-administered World Health Organization
Disability Assessment Schedule 2.0 (WHODAS 2.0). WHODAS 2.0 is a widely
used, general measure of disability and functioning with a direct conceptual link
to the ICF (WHO, 2010). WHODAS 2.0 covers difficulties experienced in six life
domains—cognition, mobility, self-care, getting along, life activities (household
activities and work/school activities), and social participation (Üstün et al., 2010).
WHODAS 2.0 items were supplemented by participants’ open-ended comments
about difficulties experienced in each domain, including employment and social
participation, which are the focuses of this study.
Part four was used to provide a summary of the assessment, including the primary
goal the participant wished to achieve through rehabilitation. When necessary,
the rehabilitation specialist helped the participant articulate this goal. During the
course of the interview, the interviewers entered all responses, both quantitative
and qualitative, into a database constructed for the study.
Data analysis
The rst author of this article reviewed each participant’s assessment survey twice in
order to understand the person’s situation and to clean the data – that is, to ensure
that all questions were answered appropriately and to identify possible coding
errors. The quantitative data were exported into an Excel spread sheet; the analysis
included frequency counts, percentages, and cross tabulations that were used to
describe participants’ demographic characteristics and their level of functioning in
each life domain. Qualitative data (participants’ comments and goals) were analysed
using systematic thematic content analysis procedures.
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
38
Results
Description of the sample
The 85 study participants ranged in age from 18 to 62. Most (71%) had a secondary
education, while 22% had primary education, 8% had a university degree, and 5%
had less than a primary education. Less than half of the participants (40%) had
acquired a profession. Half were married or lived with a partner (54%). The largest
group (34%) was unemployed due to health reasons; 32% had a paid job or were
self-employed and 6% were students. Sample characteristics are summarized in
Table 1 overleaf.
Compared to the working age population with disabilities in Estonia, our sample
contains slightly more younger people (13% vs 15% for the 18-29 age group and 13%
vs 17% for the 30-39 age group, respectively), while the 50+ age group was somewhat
underrepresented (48% vs 55%, respectively). The share of the middle age group
(40-49) in the sample was 20%, which corresponds closely to the share in Estonia’s
working-age population with disabilities. The differences in age composition are
likely due to the fact that the sample came from Estonia’s three largest cities, whose
populations tend to be younger, while proportionally more older persons reside in
smaller towns and rural areas. At 65% of our sample, women were overrepresented,
as they are 49% of the working-age population with disabilities in Estonia.
Disability had been previously determined for 65 (76%) participants; permanent
incapacity for work had been determined for 76 (89%) participants. The most
frequently identified cause of the disability was a somatic disease (for example,
diabetes, cardiovascular diseases, cancer), a psychiatric disorder, or mobility
limitations. Many had more than one type of disability (see Table 2 overleaf).
Compared to the working age population with disabilities in Estonia, persons with
somatic diseases were overrepresented in our study, while persons with intellectual
disabilities were underrepresented. The share of persons with psychiatric disorders,
mobility impairments, and sensory impairments in our sample closely matched the
respective shares in Estonia’s working age population with disabilities.
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
39
Table 1
Sociodemographic characteristics of participants (n=85) Sociodemographic
Characteristics number percentage
Age group
18-19 4 5
20-29 9 11
30-39 15 17
40-49 17 20
50-59 35 41
60-62 6 7
Gender
Female 55 65
Male 30 35
Marital Status
Never married (single) 22 26
Currently married 29 34
Cohabiting (living with partner) 17 20
Widowed 6 7
Divorced 6 7
Separated 5 6
Work status
Unemployed (due health reasons) 29 34
Paid work 24 28
Retired (in-capacity for work pension) 17 20
Student 5 6
Homemaker 3 4
Self employed 3 4
Other (on sick leave) 2 2
Non-paid work 1 1
Unemployed (other reasons) 1 1
Highest completed level of education
No formal education 5 6
Primary education (1-8 or 9 classes) 19 22
Secondary education (9-11 or 12 classes) 61 72
Higher education (university degree) 7 8
Has acquired a profession 34 40
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
40
Research question 1: Difficulties experienced in participation in
employment and society
Participants who were engaged in paid work, self employment, or unpaid work
(volunteer or charity) or in school were asked questions from the WHODAS 2.0
about the level of difficulty they had in participating in day-to-day work or school
activities. The interviewers also examined the reasons for these difficulties. Those
who were unemployed, incapacity pensioners, homemakers, or on sick leave were
not asked questions pertaining to work/school activities.
Of the 85 study participants, 32 (38%) were working (had a paid job or were self-
employed) or studying at the time of the interview. Of the 32, half (50%) reported
that in last 30 days their health condition was unstable. They noted that pain, fatigue
and exhaustion, and problems with concentration and memory reduced their work
capacity. For example: ‘Headaches cause problems, at this moment I am not able to
work.’ , ‘I’m very tired after work, I am not able to do anything anymore.’
Participants said that workloads, work tempo, and work tasks were often not
suitable given their health conditions (31%). For example: ‘The workload is too high,
but I try to manage’, ‘I am not able to do all the required tasks, to lift heavy things.’
Difficulties were also related to having to stand or sit in the same position for periods
of time, as well as a lack of suitable equipment and environmental adaptions, such
as ramps or stairs. Consequently, participants reported that their work tempo is
slowing, and in order to fulfil all the required work tasks, they need additional time
and more rest breaks. Often the failure to perform duties prescribed by workplace
Table 2
Disability status and type (n=85)
Disability status Number Percentage
Already determined 64 75
Determination in process 10 12
Disability not determined or in process 11 13
Permanent loss of working capacity
Already determined 76 89
Determination in process 3 4
Permanent loss of working capacity
not determined or in process 6 7
Type of disability
Somatic disease 29 35
Psychiatric disorder 28 33
Mobility impairment 23 27
Sensory impairment (visual and/or hearing) 4 4
Intellectual disability 1 1
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
41
norms has led to a pay reduction and also resulted in negative self-esteem or stress
(for example, ‘I am slower than others, this is causing me stress.’).
Some participants reported they lacked the skills needed to cope independently
in the workplace (for example, the ability to communicate with co-workers and
employers), or they lacked specific practical skills the job required (such as computer
skills or presentation skills). Problems were also related to insufficient clarification
of work tasks (12%). Finally, a few participants (9%) said they were not motivated
to enter the labour market or to work any more and that they had adapted to their
disability and were resigned to not working.
In examining the WHODAS 2.0 domain of participating in society, all 85
participants answered questions about difficulties they had engaging in community
activities (for example, festivities, religious, or other activities) in the same way as
anyone else, including problems due to barriers or hindrances in the world around
them. Participants were also asked to specify the cause of these difficulties. Of the
85 participants, 78% reported some type of difficulty in community participation.
The largest share (18%) reported that unstable health situations, pain or tiredness,
or inability to sit or stand in a one place for a sufficient period of time impeded
their participation in community activities. Due to mental health problems, some
became anxious or could not stand the noise or being in a large crowd of people.
Another serious problem that prevented community participation was financial
difficulties, noted by 13% of participants, such as not having suitable clothing or
inability to pay for a ticket to an event. Problems were also due to the physical
environment and transportation (11%), which were not accessible (lack of ramps,
no accessible toilet, difficulties with stairs, lack of low buses). In some cases the
person’s living place had not been modified (for example with ramps), making it
difficult for them to leave home, or they had no suitable transportation.
Additionally, some participants reported they had emotional problems, often
associated with (self) stigma and low self esteem (9%), which prevented their
participation, e.g., ‘I have been insulted by other people’, I am overweight, I do not
want to go anywhere’. Some participants added that they are very shy or that they
do not want to go alone, and they do not have friends.
Research Question 2: Participants’ rehabilitation goals
At the end of the interview, participants were asked what they wanted to achieve in
the near future. With the specialist’s help, participants formulated goals that reflected
their own personal choice about the change they wanted to achieve.
The 85 participants set 105 different rehabilitation goals. If the participant’s goal
included several sub-goals or goals in various life domains, they were separated
and listed in the appropriate domains (for example, if the goals were: ‘I would like
to get a cheaper apartment for living; I would like to find extra work’, the first goal
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
42
mentioned was listed in the field ‘living’ and the second goal in the field ‘working’).
Several participants set goals conditionally (for example, ‘I want to improve the
functioning of my left hand to be able to continue my work’); such goals were
classified in a single category (in this case, ‘health’).
Although rehabilitation in Estonia is a social service, many people expressed
goals related to health restoration. Using the ICF (biopsychosocial) rehabilitation
approach, 40% of the 85 participants set goals relating to biological aspects of their
well-being (body structures and functions). Participants wanted physical therapy
(such as physiotherapy massage, hydrotherapy) to improve their health situation.
The stabilization of a health condition was seen in many cases as a precondition for
work-related objectives. For example: ‘I hope to heal so much that I could go to full-
time work’.
Of the participants, 8% set goals in the psychological area of rehabilitation.
These included desires for counselling from a psychologist or psychiatrist to address
family problems, increase self-esteem, or reduce anxiety and negative thoughts. For
example: ‘I want to solve the complicated relations in my family’, ‘I need help from
a psychologist to restore the quality of my life’.
In the social area of rehabilitation, participants set the following goals:
UÊ /ÀÌÞwÛiÊ«iÀViÌÊÃÌ>Ìi`Ê}>ÃÊÀi>Ìi`ÊÌÊ`>ÞÊviÊVÕ`}ÊÌiÊ`iÃÀiÊÌÊÛiÊÀiÊ
independently and to reduce the need for assistance from others. For example: ‘I
want to learn how to cope more independently and keep living at my own house’,
‘I want to be more independent and take care of my daughter myself .
UÊ /ÜiÌÞvÕÀÊ«iÀViÌÊÃÌ>Ìi`ÊÜÀÀi>Ìi`Ê}>ÃÊÃÕVÊÊÜ>Ì}ÊÌÊw`ÊLÃÊÌ>ÌÊ
fit their abilities.
UÊ -ÝÊ«iÀViÌÊÃiÌÊ}>ÃÊÀi>Ìi`ÊÌÊi`ÕV>ÌÊÀÊ >VµÕÀ}ÊiÜÊ«ÀviÃÃ°ÊÀÊ
example: ‘I want to take bookkeeping courses and find work in this area’.
UÊ iÛiÊ«iÀViÌÊÃiÌÊ}>ÃÊvÀÊÃV>ÊÀi>ÌÃ«ÃÊ>`ÊiÃÕÀi°ÊÀÊiÝ>«i\ʼÊÜ>ÌÊ
to do something useful outside the home, be useful’ , ‘I would like to solve the
problems I have with my mother’.
UÊ >Þ]Ê£Ó¯ÊvÊÌiÊ«>ÀÌV«>ÌÃÊ`iVi`ÊÌÊiÝ«ÀiÃÃÊiÝ«iVÌ>ÌÃ\ÊÌiÞÊ``ÊÌÊ
want to set a goal or objective for rehabilitation, or they expressed a previous
negative experience with the rehabilitation service. Examples were: ‘I have no
expectations. Specialists wanted me to keep going on services. I do not see the
purpose of that...
Research question 3: Implications for policies and services
In Estonia, both social and vocational rehabilitation service systems are undergoing
changes. What should be considered in developing these service systems based
on our study results? Tables 3 and 4 list the factors that impeded participation in
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
43
employment and in society and outline recommendations with regard to the content
of social and vocational rehabilitation services based on study participants’ needs
and goals.
Table 3
Factors that impeded participation in employment and recommendations for the content
of vocational rehabilitation services.
Factors that impeded
employment
Recommendations for the content
of vocational rehabilitation services
Unstable health
conditions
UÊ >Ì>}Êi>ÌÊÊÜÀ«>ViÊÜiÊ«iÀvÀ}ÊÜÀÊÌ>ÃÃ
``ÀiÃÃ}Ê «>]ÊÌÀi`iÃÃ]Ê>ÝiÌÞÊÊÌiÊÜÀ«>ViÊ>`Ê
work-related stress; improving concentration, memory and
other cognitive skills
UÊ ,iviÀÀ}ÊÌÊ>`ÊV«iÀ>Ì}ÊÜÌ (occupational) health care
services (case management)
Inappropriate
workloads,
inappropriate
work tempo, and
unsuitable work
tasks
ÃÃiÃÃ}Ê «iÀÃýʫÀviÃÃ>ÊÃÕÌ>LÌÞ]ÊVVÕ«>Ì>Ê
preferences, working capacity
UÊ iÛi«}ÊÜÀÊ«iÀvÀ>Vi
UÊ `iÌvÞ}ÊÀi®ÌÀ>}Êii`Ã
,>Ã}Ê >Ü>ÀiiÃÃÊvÊÛ>ÀÕÃÊi«ÞiÌÊ ««ÀÌÕÌiÃ]Ê
e.g., providing information about flexible working conditions
(part-time work, working from home)
*ÀÛ`}Ê vÀ>ÌÊ >LÕÌÊ ÃiÌiÀi`Ê>`ÉÀÊ ÃÕ««ÀÌi`Ê
employment opportunities
UÊ ÃÕÌ}ÊÜÌÊi«ÞiÀÃÊ>LÕÌÊ>`>«Ì}ÊÜÀ>`Ã]ÊÜÀÊ
tempo, and tasks to make them suitable for the person
Lack of suitable
working skills
UÊ /i>V}ÊÃÃÊ«À>VÌV>ÊÜÀÊÃÃ]ÊVÕV>ÌÊÃÃ]Ê
computer skills, etc.)
Low motivation UÊ ÃÃiÃÃ}Ê>`ÊVÀi>Ã}ÊÀi>`iÃÃÊvÀÊV>}i
UÊ iÛi«}Ê«iÀÃ>ÊÌÛ>ÌÊ>`ÊÃÕ««ÀÌ}ÊÀi>`iÃÃÊvÀÊ
employment (e.g., positive self-esteem, experience of success,
adapting to work rol2000)es)
UÊ *ÀÛ`}ÊÃV>ÉÀiVÀi>Ì>Ê>VÌÛÌiÃ
Physical
environment
in workplace,
transportation
ÃÃ i ÃÃ }Ê ÌiÊÜÀÊiÛÀiÌÊÀiµÕÀiiÌÃÊ>`Ê
adjustments needed)
`ÕVÌ}Ê vÕVÌ>Ê>ÃÃiÃÃiÌÊvÊViÌÊÊÜÀ«>ViÊ
(listing critical skills, describing skills use, evaluating skills
functioning, coaching)
/i>V}Ê ÃÃÊvÀÊ«ÀÛ}ÊvÕVÌ}ÊÊÌiÊ«ÞÃV>Ê
environment, using transportation, improving mobility,
learning itineraries
UÊ /i>V}ÊÜÊÌÊÕÃiÊÌiVV>Ê>`ÃÊ>`ÉÀÊ«iÀÃ>Ê>ÃÃÃÌ>Ì]Ê
adapted transportation
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
44
Table 4
Factors that impeded participation in society in general and recommendations for the
content of social rehabilitation services
Factors that impeded
participation in
society in general
Recommendations for the content
of social rehabilitation services
Unstable health
conditions
>Ì >}Ê i>Ì Ê >`Ê«ÀÌ}Ê>Ê>VÌÛiÊviÃÌÞiÊÜiÊ
living with a disease or adapting to disability
UÊ ``ÀiÃÃ}Ê«>]ÊÌÀi`iÃÃ]Ê>ÝiÌÞÊ>`ÊÌiÀÊÃÞ«ÌÃ
*ÀÛ`}Ê i>ÌÀi>Ìi`Ê>`ÊÌiÀ>«iÕÌVÊÃÕ««ÀÌÃÊi°}°]Ê
rehabilitation programs based on diagnosis or type of disability
such as programs for those with rheumatic diseases, Parkinson‘s
disease, multiple sclerosis)
Financial difficulties UÊ ÃÃiÃÃ}Ê ÀiÃÕÀViÃÊÃÌ}Ê>`ÊiÛ>Õ>Ì}ÊVÀÌV>Ê ÀiÃÕÀViÊ
use, coaching)
/i>V}Ê ÃÃÊÃÕVÊÊÜÊÌÊLÌ>ÊiViÃÃ>ÀÞÊÀiÃÕÀViÃÊ
according to the individual’s needs (financial aid, supported
living, clothing, food)
UÊ *ÀÛ`}ÊvÀ>ÌÊ>LÕÌÊ>VÌÛÌiÃÊÌ>ÌÊ>ÀiÊvÀiiÊvÊV>À}iÊ
(church, disability union, concerts, social events)
UÊ *ÀÛ`}ÊvÀ>ÌÊ>`Ê«À}À>ÃÊÌÊ«ÀÌiÊVÕÌÞÊ
participation and utilisation of mainstream services such as
day centres or home services
Mobility limitations:
movement
in physical
environment
and using public
transport
Û`vÕVÌ>Ê>ÃÃiÃÃiÌÊÃÌ}ÊVÀÌV>ÊÃÃ]Ê
describing skills use, evaluating skill functioning, coaching)
UÊ /i>V}ÊÃÃÊÊÜÊÌÊ«ÀÛiÊvÕVÌ}ÊÊÌiÊ«ÞÃV>Ê
environment; improve mobility (how to use transportation;
learn suitable itineraries)
UÊ 1Ã}ÊÌiVV>Ê>`ÃÊ>`ÉÀÊ«iÀÃ>Ê>ÃÃÃÌ>ÌÃÊ
Emotional
problems and (self)
stigmatisation
/i>V}Ê >LÕÌÊÜÊÌÊÛiÀViÊ`i«ÀiÃÃÊ>`ÊÜÊÃiv
esteem and deal with negative thoughts and emotions
UÊ iÛi«}ÊÌÛ>Ì]Ê«Ài«>Ài`iÃÃ]Ê>`Êi«ÜiÀiÌ
UÊ *ÀÛ`}ÊvÀ>ÌÊ>LÕÌÊÃÕÌ>LiÊiÃÕÀiÊ>VÌÛÌiÃÊÌÊÀ>ÃiÊ
interest and motivation to participate
UÊ `ÕV>Ì}ÊÌiÊ«ÕLVÊÌÊVL>ÌÊÃÌ}>Ê>`Ê`ÃVÀ>Ì
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
45
Discussion
This article reported on the difficulties that persons with a disability or reduced work
capacity are facing in employment and in societal participation. We also looked at
the rehabilitation goals that people with disabilities set for themselves and addressed
what the content of social and vocational rehabilitation services should be as Estonia
initiates broad changes in its rehabilitation system.
The study reveals that the barriers that impede participation in the labour
market and in the community are multiple, complex, and rarely connected with
only one area of life. Still, many barriers that participants reported were related to
their health. A large number identified themselves as unemployed due to a health
condition which resulted in difficulties keeping up with workloads or work tempo,
work tasks not suitable to their current health condition, barriers in the physical
environment, and low motivation. The study confirmed findings of other studies
stating the need for better lifelong learning opportunities (OECD, 2012) and the need
for part-time work and flexible work schedules where people with disabilities can
adjust their job according to their health conditions (Wilken et al., 2014). Factors
that impede participation in society were also connected with mobility limitations,
financial difficulties, and emotional problems. A biopsychosocial approach and the
ICF-based assessment instrument made the assessment process holistic and person
centred (WHO, 2006; Peterson, 2005; Lakhan, 2006).
Given participants’ concerns about their health conditions and unmet health
needs, rehabilitation goals related to health restoration were mentioned most often
followed by goals connected with the social domain of rehabilitation–living and
coping more independently. Employment-related goals ranked third, which is
understandable since people may not think about going to work until they feel well
or healthy enough to manage in the work environment (when their health is stable)
and living-related issues have been resolved. Still, only 6% of participants set goals
related to education or acquiring a profession, and 12% expressed no rehabilitation
goal. There might be different explanations for these findings. People may mistrust
services, or they may not be ready to engage in a rehabilitation process, possibly
due to a lack of self-confidence. It might also be that people need more support and
information to develop a rehabilitation goal based on personal choice, especially
if they feel discouraged by their current health situation or disability. The findings
suggest that among people with disabilities, shifts in attitudes about their abilities
to work and expectations about their rights to work will be necessary to increase
employment.
As the main barrier participants reported was unstable health conditions,
services aimed at improving employment and participation should include direct
assistance to improve health status, or case management to aid people with
disabilities in obtaining necessary health care services. Countries like Estonia
must address insufficient service capacity in the health care sector, including
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
46
long waits to see specialist doctors, if the country’s disability reform policies are
to be successful. Vocational rehabilitation services must help employers as well
as employees. Employees might need assessment of professional suitability and
occupational preferences, services designed to develop their work performance,
including (re)training, increased awareness of various employment opportunities,
and skills training and advice to maintain their health in the workplace. Employers
need information about the capabilities as well as the needs of people with
disabilities and counselling about how to make the work environment more
conducive to people with disabilities. Much depends on the attitudes and efforts of
employers, who can contribute by adapting the physical work environment, which
is often easier and less expensive than employers’ think, offering flexible working
conditions, and creating a supportive atmosphere at the workplace. Estonia’s new
system of supporting entry or re-entry to the labour market should address these
factors.
Recommendations
Based on the difficulties that impeded participation in employment and in society
coupled with shortcomings noted in national and international studies about
Estonian systems, policy change is needed to support people with disabilities or
reduced work capacity in entering or re-entering the labour market. We recommend
the following:
1. The content of rehabilitation services should be tailored to the individual needs
of persons with disabilities in order to increase the likelihood of successful
rehabilitation.
2. Services aimed at improving employment and participation should include
assistance to improve health status or case management to aid in obtaining
necessary health care services as a precursor to employment-related rehabilitation
services.
3. Comprehensive (holistic) and person-centred assessment, service planning, and
budgeting processes that provide flexible opportunities are needed to ensure that
people with disabilities receive sufficient services rather than imposing fixed
limits on the volume of services per calendar year without regard to individual
need.
4. Modification of the physical environment and accessible transportation are
necessary to increase participation in employment and society.
5. Clear case management responsibilities for agencies providing social and
vocational rehabilitation services should be specified in order to ensure that
other services (for example, healthcare services) are available to meet clients’
PROMOTING EMPLOYMENT AMONG PEOPLE WITH DISABILITIES
47
needs and continuing support is provided for as long as needed to assist the
person in achieving their rehabilitation goals.
6. Given that two-thirds of the sample was not working, it is important to increase
lifelong learning opportunities for persons with disabilities or reduced work
capacity to aid them in acquiring a new profession or completing their studies
and improving their opportunities in the labour market.
Conclusion
For too long, like other countries, Estonia has viewed people with disabilities as
outside the workforce and has relied on pensions as the major form of social support.
To improve the situation, state and local governments can do a great deal by offering
adequate health services, creating or organizing accessible transport systems,
providing good examples of accessible working environments, and offering suitable
rehabilitation services for employees and employers. Many of these changes require
both financial support and specific knowledge. First and foremost, it is important
that the general public, employers, people with disabilities, and policymakers view
people with disabilities in a new light by sharing experiences and learning from
each other. The various stakeholders, including people with disabilities, must be
included in the discussion.
Our study makes clear that some people with a disability regard themselves as
too disabled to participate in community or work activities. This may be a result
of stigmatisation, negative (self)labelling, and/or low (self)esteem. Others find that
despite their desire to work and engage in community activities, work sites and other
places are not welcoming of people with disabilities. Disability is always caused
by an interaction between personal and environmental factors. Obviously, health
conditions can cause substantial difficulties, but poor and fragmented services and
prejudices are to blame for the poverty and low unemployment rates of people with
disabilities. A new government policy can address the changes that are needed to
help people with disabilities participate fully in society.
Acknowledgements
The authors would like to thank professor Lauri Leppik, Senior Research Fellow,
Estonian Institute for Population Studies, Tallinn University and research team
members, interviewers, representatives of the Ministry of Social Affairs and Astangu
Vocational Rehabilitation Centre.
KARIN HANGA, DIANA M. DINITTO, AND JEAN PIERRE WILKEN
48
Declaration of interests
The authors declare no potential conflicts of interests with respect to the research,
authorship and/or publication of this article. The research project was implemented
by Astangu Vocational Rehabilitation Centre, Estonia, and funded by the European
Social Fund.
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... The largest distinctive client group of social rehabilitation efforts is patients with a clear medical diagnosis or an impairment, which, by extension, affects their social life. This group includes people with neurological problems (e.g., traumatic brain injury; Tate et al., 2003;Ylvisaker & Feeney, 2000), neurological patients (Portillo & Cowley, 2011), psychiatric patients with mental illness (Koichi et al., 2009;Lucca & Allen, 2001;Myers, 1980;Semba et al., 1993;Weisman, 1985), and people with disabilities (Hanga et al., 2015(Hanga et al., , 2017Kolo, 1996). Hanga et al. (2015, p.32) also use the expression people with "reduced work capacity", which can refer to either a medical diagnosis or some other cause such as emotional problems. ...
... On the other end of the continuum, there are community-based services or programs, which include interventions by and meetings with different professionals as well as other activities. Most of them take place in settings such as the home of the client, a caf e, a community center, or other communal facility, for example, in case of discharged traumatic brain injury patients (Ylvisaker & Feeney, 2000), persons with disabilities or reduced work capacity (Hanga et al., 2015), homeless persons (Piechowicz et al., 2014), children with multiple problems (Sefarbi, 1986), and mentally ill patients (Koichi et al., 2009). In addition to the practices described earlier, social rehabilitation takes place within other institutions such as prisons (Becker-Pestka, 2017;Muro et al., 2016), residential facilities for older adults (Arnetz & Theorell, 1987), or hospitals Portillo & Cowley, 2011). ...
... The actual services offered under the title 'social rehabilitation' are manifold. Social rehabilitation covers services from social assessments to therapy (e.g., Hanga et al., 2017;Portillo et al., 2009;Portillo & Cowley, 2011), counseling, and coaching (e.g., Hanga et al., 2015;Piechowicz et al., 2014;Ylvisaker & Feeney, 2000); from educative groups (e.g., Becker-Pestka, 2017) to actual vocational training (e.g., Aborisade & Aderinto, 2008a;Hanga et al., 2015;Koichi et al., 2009) or job hunting (Sefarbi, 1986); and from solving relationship or communication problems (e.g., Savard et al., 2013;Ylvisaker & Feeney, 2000) to recreational activities and outings (e.g., Arnetz & Theorell, 1987;Lucca & Allen, 2001). ...
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Social rehabilitation is conceived to encompass services that concentrate specifically on the social aspect of the rehabilitation process. This interpretive qualitative meta-synthesis of 25 social scientific research papers published between 1980 and 2019 dealing with the concept of social rehabilitation aims to unpack the different dimensions of the social within social rehabilitation in different contexts. Findings In most of the articles, the causes for social rehabilitation are located in the rehabilitee’s social environment, community, or structure, and for the rehabilitation to be successful, a change is expected to take place also in these parties. Moreover, personally significant values and wishes are emphasized in many approaches viewing the rehabilitee as an agent in his/her own rehabilitation process. In a few articles, however, the individual is viewed as aberrant, and his/her conforming to societal norms is seen as forming the core of social rehabilitation. In this approach, the individual is viewed as the object of rehabilitation without much control over his/her own rehabilitation process. Applications The results of our study suggest that, to improve existing social rehabilitation practices, more effort should be put into acknowledging and considering the rehabilitee’s autonomy as a relational concept. Also, the needs for, foci, and aims of social rehabilitation should not be reduced to a certain kind of practice directed to certain kinds of client groups, but, rather, social rehabilitation should be understood as an entity consisting of interrelated and interdependent components forming a constantly shifting assemblage.
... According to the Manual for WHO Disability Assessment Schedule, [25] WHODAS 2.0 is available in more than 30 languages. We found that WHODAS 2.0 was administered in 47 languages and dialects; the following is a list of the first reported translations in each case: Amharic, [118] Arabic, [119] Bengali, [120] Chinese, [121] Danish, [122] Dari, [123] Dutch, [124] English, [125] Estonian, [126] Farsi, [127] French, [128] Georgian, [129] German, [130] Greek, [131] Haitian Creole, [132] Hebrew, [133] Hindi, [134] Indonesian, [135] Italian, [136] Japanese, [137] Kannada, [138] Kinyarwanda, [139] Korean, [140] Krio, [141] Latvian, [83] Luganda, [142] Lusoga, [143] Malayalam, [144] Nepali,[145] Norwegian, [146] Polish, [147] Portuguese, [148] Russian, [149] Slovenian, [150] Spanish, [151] Swedish, [152] Tamil, [153] Thai, [154] Tok Pisin, [155] Turkish, [156] Twi, [157] Ukrainian, [149] Urdu, [158] Xhosa, [159] Xitsonga, [160] Yoruba, [161] and Zulu [162] (Supplementary Table S1). ...
... Finally, 7% (n ¼ 61) of the studies administered a subset of WHODAS 2.0 items selected for their relevance to the research in question. [113,126,128,135,149,154,165,172,173,182,187,214,230,231,235,236,255,259,330,340,346,347,350,352,362,378,380,381,406,413,415,433,448,450,457,471,495,502,503,535,548,554,580,584,631,633,640,656,684,697,698,714,[835][836][837][838][839][840][841][842][843] Forty-eight of the 811 selected studies reported the psychometric properties of WHODAS 2.0. [24,25,80,86,121,124,125,130,136,137,139,143,144,151,156,188,206,207 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 [25,121,124,125,130,136,137,139,144,151,156,254,268,269,324,520,549,571,577,595,620,622,638,640,671,679,736,769,799] As shown in Table 1, the alpha coefficients for the total score indicate that the 36-item and WMH-WHODAS versions have excellent internal consistency in all languages (alpha !0.90). ...
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Purpose: This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument. Method: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on “whodas” using the ProQuest, PubMed, and Google Scholar electronic databases. Results: We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry). Conclusions: The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single “minimal clinically important .difference” score for the WHODAS 2.0 has not yet been established.
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