Perceived barriers to and facilitators of labor market engagement for individuals with chronic physical illness in their experience with disability policy: a systematic review of qualitative evidence protocol

Review question / objective Two research questions will be addressed. These are, from the perspective of individuals with chronic physical illness: what are the barriers in disability policies with respect to labor market engagement? what are perceived facilitators in disability policies with respect to labor market engagement? The objective of this review is to identify and synthesize the best available evidence regarding barriers and facilitators that exist at the policy level with respect to labor market engagement (i.e. gaining and maintaining employment), from the perspective of individuals with chronic physical illness. Background According to the World Health Organization, over one billion people or about 15% of the world's population live with a disability,1 including an estimated 386 million of the world's working-age population.2 Among the 34 developed and emerging countries in the Organization for Economic Co-operation and Development (OECD), a global organization that promotes policies to “improve the economic and social well-being of people around the world”,3(para1) these figures translate into 14% of the working-age population living with a disability.4 It is projected that these numbers will continue to rise due to an aging population, increased longevity and a global increase in chronic illnesses, such as cardiovascular disease, cancer, diabetes and respiratory diseases.1 Despite research indicating that employees with disabilities have better retention rates than those who do not,2 and that employers who hire individuals with disabilities outperform their competitors,5 unemployment among disabled persons is as high as 80% in some countries.2 These statistics not only speak of the growing number of working-age disabled individuals worldwide, but also the difficulties they face in terms of labor market engagement.1 Disability refers to “impairments, activity limitations and participation restrictions”.1(p4) Although there are numerous different definitions of disability in literature, it is generally acknowledged that disability arises from an interaction between health conditions and personal and environmental factors.1 A widely used definition is that of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) where disability is conceptualized as resulting “from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others”.2(p1) Although any of a number of conditions, such as developmental conditions, sensory impairments, injuries and infectious diseases, may contribute to disability, chronic illnesses are the leading contributory cause of disability worldwide1,6 and the onset often occurs during an individual's prime working years.7 The worldwide socio-economic impact of chronic illness in the working population is well recognized,1 and includes unemployment,4,8 premature withdrawal from employment,9,10 decreased productivity due to absenteeism and presenteeism,10,11increased health care costs, reduced tax revenues and increased welfare spending.10But there are human costs too - social exclusion, stigma, poverty, decreased self-efficacy, and increased burden on families and caregivers.1,10 Furthermore, the relationship between illness and employment is bi-directional with unemployment and underemployment having adverse health effects, such as depression and substance abuse, and leading to an increase in symptoms of chronic illnesses.12 It seems that regardless of one's ability status, work is good for mental and physical health. Yet, individuals with chronic illnesses and resulting disability face many challenges in gaining and maintaining employment. Although personal health-related factors, such as mobility limitations, fatigue, pain and symptom flare-ups can account for some of the challenges,7,13 system factors, in particular, work disability policies, are also at play. Work disability policy refers to guidelines and rules pertaining to non-monetary benefits, supports and financial compensation relative to work; employment; and integration into the work force for individuals with disability. It includes policy from various sources: government level programs relevant to income security and labor market engagement, private disability pension plans, disability and accident insurances, trade union agreements and employers. There are cross country differences among disability policies with respect to the definition of disability, eligibility requirements, benefit recipiency and employment incentives.14 Despite these differences, work disability policies worldwide share two overarching aims, i.e. to provide: 1) financial compensation to individuals whose disability is preventing or compromising their ability to work and earn a decent wage, and 2) employment-oriented programs to encourage labor market engagement, often referred to as integration.15 Over the past few decades, within the OECD, there has been a steady trend away from compensatory polices and towards integration policies.16 It has been argued that the reason many disabled persons are not working is due to policy failure.15 Within the CRPD, policy inadequacies and a lack of policy enforcement were identified as restricting both social and labor market engagement for individuals with disabilities.2 Research conducted by the International Labor Organization revealed that state laws protecting disabled workers can in fact increase the reluctance of private companies to hire them and social insurance programs can discourage a return to work.17 Individuals living with chronic physical illnesses may encounter challenges with work disability policies. They can experience a fragmented disability policy system18 that is more suited to individuals with acute injuries and illnesses than to individuals whose ability to work can fluctuate.13 Individuals who are chronically physically disabled are not a homogeneous group and the specificity of eligibility requirements can lead to many falling between the cracks.13,19 However, just as there are policies that impose barriers to labor market engagement of individuals with chronic physical illness, there are also policies that facilitate their labor market engagement.20,21 What constitutes disability policy barriers and facilitators to labor market engagement for individuals with chronic physical illness is best understood from the perspective of the individuals themselves. A preliminary review of literature indicates that qualitative studies exist on the perceptions of individuals living with chronic physical illnesses in relation to experiences with policy that is prohibitive or facilitative of labor market engagement. It is anticipated that a systematic review of such studies will enable understandings so as to inform recommendations for work disability policy that meets the needs of individuals with chronic physical illnesses. A search of the JBI Database of Systematic Reviews and Implementation Reports, the Campbell Library, the Cochrane Library, Google Scholar and the PROSPERO, CINAHL and PubMed (MEDLINE) databases was conducted to determine whether any systematic reviews had been conducted to date about disability policy and labor market engagement. Twenty-one review documents relevant to disability and employment were retrieved and examined. These consisted of: (a) a narrative literature review on job retention strategies7; (b) a protocol for a systematic review on labor market interventions in low- and middle-income countries22; (c) three scoping reviews examining the influence of chronic pain on work23, employment programs, policies and interventions21, and meaning of work24; (d) a systematic review of topics and trends in research on interventions for work-related musculoskeletal disorders25; (e) six systematic reviews on evaluation or effectiveness of employment or workplace interventions26-28, three of which included qualitative studies20,29,30; (f) three systematic reviews on the impact of chronic pain in the workplace31, employee quality of life32, and determinants of continued employment33, two of which included qualitative studies32,33; and (g) six qualitative systematic reviews on employment experiences.34-39 However, no review was found that focused on barriers and facilitators, from the perspective of individuals with chronic physical illness, at the policy level with respect to labor market engagement.

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