Australian Occupational Therapy Journal (2014) 61, 335–343

doi: 10.1111/1440-1630.12133

Research Article

Contextual influences on employment of people with dual diagnosis: spinal cord injury and traumatic brain injury Claire L. Boyle,1,2 Melissa T. Nott,3 Ian J. Baguley1,4 and Judy L. Ranka5 1 Brain Injury Rehabilitation Service, Westmead Hospital, Sydney, 2Moorong Spinal Unit, Royal Rehabilitation Centre Sydney, 3School of Community Health, Charles Sturt University, Albury, 4School of Medicine, The University of Sydney, and 5Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia

Background/aim: Research into the paid employment of people with spinal cord injury or traumatic brain injury is prevalent; however, little research has examined the factors that may support employment for adults with a concomitant spinal cord injury and traumatic brain injury (dual diagnosis). This study aimed to determine the level of paid employment reported by people with dual diagnosis and to explore contextual factors that supported paid employment. Methods: This cross-sectional cohort study recruited 30 participants with dual diagnosis from a specialist spinal rehabilitation unit. Interviews were conducted during the first five years post-rehabilitation discharge to determine level of paid employment and contextual factors that supported employment. Results: At interview, 47% of participants were in paid employment. Employment type at interview indicated a shift away from more physically intensive jobs. Employed and unemployed participants reported a high level of social support and reported experiencing few physical or attitudinal barriers in their day to day lives. These environmental factors did not differentiate between employed and unemployed participants (z range = 0.98 to 0.17; P value range = 0.33–0.86). The most common facilitator of employment identified by participants was the personal factor – motivation (93% of employed participants). Conclusion: When considering the impact of contextual factors on paid employment for people with a dual diagnosis of spinal cord injury/traumatic brain injury, personal factors may be of greater influence than environmental Claire L. Boyle MOT, BEd (Special Education); Occupational Therapist. Melissa T. Nott PhD, BAppSc (OT) (Hons); Lecturer. Ian J. Baguley PhD, MBBS; Research Team Leader. Judy L. Ranka MA, BSc (OT), HlthScD; Honorary Lecturer. Correspondence: Dr Melissa T. Nott, School of Community Health, Charles Sturt University, PO Box 789, Albury, NSW 2640, Australia. Email: [email protected] Accepted for publication 24 March 2014. © 2014 Occupational Therapy Australia

factors. Study participants experienced few physical or attitudinal barriers and reported highly supportive interpersonal relationships. KEY WORDS ICF, spinal cord injury, traumatic brain injury, work.

Introduction The presence of concomitant spinal cord injury (SCI) and traumatic brain injury (TBI) (henceforth termed Dual Diagnosis or DDx) has been well documented with incidence rates reported to be between 24% and 59% (Macciocchi, Seel, Thompson, Byams & Bowman, 2008; Zafonte, Elovic, Kirshblum, Campagnolo & DeLisa, 2002). The wide-range in reported incidence rates reflects the variability in study methodology, especially in terms of inclusion criteria and the definition of what constitutes TBI. In the event of a spinal trauma, the possibility of a TBI component to the injury is often not considered until a few days after the trauma or, in the case of mild TBI, sometimes not at all (Macciocchi et al.). However, the sequelae of DDx can include deficits reflecting contributions from both SCI and TBI. Research into the acute rehabilitation outcomes of people with DDx has generally suggested that people with a DDx make reduced functional gains compared to those with single diagnosis SCI (Bradbury et al., 2008; Macciocchi, Bowman, Coker, Apple & Leslie, 2004). However, recent research has challenged these findings by identifying an interaction between the severity of cooccurring TBI/SCI and functional outcomes. In a prospective study of 189 adults with SCI, quadraplegia with co-occurring TBI was not related to motor outcomes despite cognitive impairments. Further, in adults with paraplegia, only presence of severe TBI impacted motor outcomes, whereas presence of mild or moderate TBI did not appear to impact on motor outcomes (Macciocchi, Seel, Warshowsky, Thompson & Barlow, 2012). Research into DDx does not currently extend beyond the rehabilitation stage and so the effect of DDx on employment following rehabilitation is not known. The

336 majority of SCI, TBI and DDx injuries occur during critical productivity years of the lifespan (Anderson, Dumont, Le Bourdais & Noreau, 2007; Khan, Baguley & Cameron, 2003) and may negatively influence engagement in work and employment, one of the major life areas included in the International Classification of Functioning (ICF) framework (World Health Organisation, 2012). Adopting an approach that parallels occupational therapy, the ICF framework considers function and disability as outcomes of the interactions between health conditions and contextual factors. These contextual factors include external environmental factors (for example, social attitudes and physical characteristics such as access, climate and terrain); and internal personal factors that influence how disability is experienced by the individual, which are not represented elsewhere in the ICF including gender, age, coping styles and social background (World Health Organisation, 2002, 2013). When considering the relationship between contextual factors and the major life area of paid employment, there is little evidence to guide occupational therapy practice with adults who have sustained a DDx. Further, there is conflicting research that explores the influence of environmental factors on people with single diagnoses of SCI and TBI, as research has reported various environmental factors that both support and inhibit employment (Anderson et al., 2007; Burns, Boyd, Hill & Hough, 2010; Fiedler, Indermuehle, Drobac & Laud, 2002; Jongbloed, Backman, Forwell & Carpenter, 2007; Murphy, Middleton, Quirk, De Wolf & Cameron, 2009, 2011; Noreau, Dion, Vachon, Gervais & Laramee, 1999; Tomberg, Toomela, Pulver & Tikk, 2005; Wagner, Hammond, Sasser & Wiercisiewski, 2002; Whiteneck, Gerhart & Cusick, 2004). Against this background, the aim of this study was to begin identifying the contextual factors which are critical in supporting the employment of people with DDx of SCI/TBI, primarily focusing on external environmental factors.

Materials and methods Design and sample This cross-sectional cohort study was approved by the Northern Sydney local health Ethics Committee, The University of Sydney and Macquarie University. All applicable institutional and governmental regulations concerning ethical conduct with human participants were followed during this research and all participants gave informed consent. Participants were identified from a single spinal rehabilitation unit’s discharge database. The following selection criteria were applied to consecutive discharges from 1 January 2003 to 31 December 2008: first incidence traumatic SCI with concomitant TBI, aged 18–75 years at the time of injury and conversational level English. Screening of the electronic discharges database positively identified 36 patients classified as dual diagno-

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sis. The remaining 168 medical records were hand searched to identify undiagnosed cases of concomitant brain injury. Positive identification of 39 additional patients was made when the acute medical record or ambulance report included one or more of the following indicators: loss of consciousness at scene of accident, Glasgow Coma Scale (Zuercher, Ummenhofer, Baltussen & Walder, 2009) less than 15, or abnormal brain imaging. When available, Neuropsychological evaluation was then used to confirm presence of cognitive impairment. Severity of TBI was determined using duration of post-traumatic amnesia (PTA; Shores, Marosszeky, Sandanam & Batchelor, 1986) based on prospective assessment of PTA for severe to very severe TBI, and retrospective assessment for those with mild TBI (Gronwall & Wrightson, 1980). Severity of SCI was indexed by neurological level of SCI (cervical, thoracic, lumbar), and on American Spinal Injury Association score (ASIA; American Spinal Injury Association, 2000).

Data collection A structured interview based on standardised outcome measures was conducted with participants, in their homes, at the rehabilitation centre or via telephone. Demographic and injury related data were collected from hospital databases and medical records. Scores on the Functional Independence Measure (FIMTM; Keith, Granger, Hamilton & Sherwin, 1987) at rehabilitation admission and discharge were collected from the medical record. The FIMTM was also administered during the interview via self-report, to evaluate current functional level. The primary dependent variable, paid employment, was determined by the Vocational Questionnaire (VQ), a measure developed by the New South Wales State Spinal Service (available from the NSW State Spinal Service). Employment status was determined by participants’ response to a closed, multiple choice questions on the VQ: ‘At present, what is your main occupational status?’ Options included combinations of employed in paid work, volunteer work, studying, engaged in a rehabilitation programme, domestic duties, retired and unemployed. Job type at the time of injury and at interview were categorised using the Australian Standard Classification of Occupations (ASCO; Australian Beaureau of Statistics, 1997). A secondary question on the VQ asked participants to rank, from a provided list, the most common facilitators and barriers to resuming employment after their injury. Facilitators and barriers included factors that mapped to three main areas of the ICF framework: body functions, personal factors and environmental factors. Previously published ICF linking rules were followed (Cieza et al., 2002, 2005). Facilitators that mapped to body functions included ongoing health issues such as pain (b280 Sensation of pain) and unpredictable mood (b126 Temperament). Personality factors such as

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personal motivation were self-identified as facilitators (not indexed in the ICF). Several environmental factors were identified as potentially being either a facilitator or a barrier. Availability of workplace modifications (e150 Design, construction and building products and technology of buildings for public use) and adaptive equipment (e135 Products and technologies for employment) were mapped to ICF Environment Chapters 1 and 2, and environmental factors drawn from Chapters 3 and 4 included family support (e310 Support of immediate family) and employer attitude (e430 Individual attitudes of people in positions of authority). Access to vocational training (d825 Vocational training) and/or vocational rehabilitation services (e590 Labour and employment services, systems and policies) could alternatively be a facilitator or barrier depending on the individual’s needs and the level of training/service availability. In addition to the self-reported environmental factors indexed by the VQ, environmental factors potentially influencing employment were further evaluated with two standardised measures: The Sydney Psycho-social Reintegration Survey (SPRS; Tate, Hodgkinson, Veerabangsa & Maggiotto, 1999) and the Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF; Whiteneck, Gerhart, et al., 2004). Part-B of the SPRS was used to evaluate interpersonal relationships. Links to the ICF were made using previously published ICF linking rules (Cieza et al., 2002, 2005). The four items from SPRS-Part B link to the ICF Environmental Factors Chapter 3: Support and Relationships with immediate family (e310), friends/neighbours/colleagues (e320/e325) and the ICF Activities and Participation Domain Chapter 3: Communication, involving speaking to others (d330), understanding what others say/receiving spoken messages (d310) and conversation (d350). Items are self-rated on a six-category scale with higher scores indicating better interpersonal functioning. The SPRS has high internal consistency (a = 0.90) and inter-rater reliability (ICC = 0.95; Tate et al., 1999). The construct validity of the SPRS has been demonstrated in adults with TBI, with strong convergent and discriminant validity (Tate et al.). The CHIEF-SF (Whiteneck, Harrison-Felix, et al., 2004) was used to evaluate the influence of external environmental factors such as physical aspects of the environment, attitudes of other people, and the systems, services and policies that influence occupational engagement. Four domains of the CHIEF-SF were linked to the ICF Environmental Factors Chapters 1 to 5 using published ICF linking rules (Cieza et al., 2002, 2005). The CHIEF-SF domain of Policies mapped to the ICF Environmental Factors Chapter 5: Services, systems and policies, related to health (e580), open space planning (e520), transportation (e540) and social security (e570). The CHIEF-SF Physical and Structural domain mapped to the ICF Environmental Factors Chapter 2: Natural environment (e225 Climate and e210 Physical Geography) and human-made

aspects to the environment such as lighting (e240 Light), noise (e250 Sound) and crowds (e215 Population). The Work and School Domain of the CHIEF-SF linked to Chapters 4 and 5 of the ICF Environmental Factors focusing on Education and training services, systems and policies (e585), and Labour and employment services, systems and policies (e590). In addition, the CHIEF Work and School Domain also included attitudes of people in the school or work environment (e425 Attitudes of peers and colleagues, e430 Attitudes of people in positions of authority). The final CHIEF-SF Domain evaluated in this study was Attitudes and Services, which mapped to ICF Environmental Factors Chapter 4: Attitudes. The CHIEF-SF is a self-report measure with high internal consistency (a = 0.76–0.93) and test-retest reliability (ICC = 0.93; Whiteneck, Harrison-Felix, et al., 2004). Participants report the frequency at which each environmental barrier has been experienced in the preceding 12-month period and the magnitude of the problem. The construct validity of the CHIEF-SF has been established using factor analysis with various diagnostic groups including SCI and TBI (Whiteneck, Harrison-Felix, et al.).

Analysis A dichotomous variable was created to categorise participants based on their employment at time of interview. Participants who reported being in paid employment were classified as ‘employed’. All other participants were classified as ‘unemployed’, including those involved in volunteer work, study, home management and participants who reported not being in paid employment. The exclusion of voluntary work or study from the ‘employed’ classification was chosen to enable comparison to other research on the employment of people with SCI and TBI. A more inclusive definition of ‘productive engagement’ including paid employment, volunteer work and study has been used previously (Boyle et al., 2013). Frequency statistics were used to identify the most common facilitators and barriers to resuming employment. Descriptive statistics were used to characterise the sample at injury, rehabilitation discharge and at the time of interview. Differences between the employed and unemployed groups at injury and rehabilitation discharge were examined for potential confounds using chi-square analysis, Mann–Whitney U-tests and independent group t-tests as appropriate. To identify the environmental factors which may influence the employment of people with DDx, the SPRS Part B and relevant CHIEF-SF subscale scores of employed participants were compared to unemployed participants using Mann–Whitney U-tests. Differences between groups were considered significant at P < 0.05.

Results From the spinal rehabilitation unit database, a total of 75 people met the dual diagnosis inclusion criteria from © 2014 Occupational Therapy Australia

338 a total discharge number of 204. Of these, 30 consented to participate. At the time of their injury, 27 (90%) were employed and 14 reported being employed at the time of their interview (47%). Half the participants had sustained a complete SCI (ASIA A). One-third sustained cervical level injuries, 53% had sustained thoracic injuries and the remaining 14% sustained lumbar injuries. The median PTA duration was 12 days (Shores et al., 1986): 27% sustained a mild-moderate TBI; 57% sustained a severe-very severe TBI; and 16% sustained an extremely severe TBI. There were no confounding factors evident between the employed and unemployed groups on the basis of demographic, injury or rehabilitation variables (Table 1), therefore groups were determined to be equivalent. With respect to personal factors, the sample was predominantly men with a mean age of 42 years, median of 12 years education plus two years of tertiary/TAFE education. Most injuries were sustained in a motor vehicle accident (60%). There were no statistical differences between the groups based on relationship status at injury (v2 = 2.1, P = 0.14) or at interview (v2 = 1.2, P = 0.28) though a higher proportion of people in the employed group were married or cohabiting with their partner at injury (64%) and the time of interview (57%).

Types of employment Investigation of participants’ employment type at injury and interview suggested a shift away from more physically intensive jobs (for example, labouring) which is consistent with the physical limitations that result from SCI and TBI (Table 2). Activities that may support return to previous or alternative employment, such as studying or vocational retraining were not engaged in by many study participants. Of the participants, who were not employed at interview only two were studying and one was engaged in a vocational rehabilitation program. These three participants were employed in trades and transport related activities at the time of their injuries (ASCO Code 4 and 7). These areas of employment were observed to be associated with the greatest level of change in employment following injury.

Environmental factors Interpersonal relationships were the first environmental factor to be evaluated in this study. Both the employed and unemployed groups rated their level of relationship support and their communication abilities quite highly in SPRS Part B, indicating that all participants felt they had good support from their immediate family, extended family, colleagues and friends. The level of support gained from interpersonal relationships was statistically similar between the employed and unemployed groups (Table 3) and did not appear to be a differentiating factor in this sample. This is consistent with © 2014 Occupational Therapy Australia

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the number of participants married or cohabiting with a partner (57% of employed participants; 38% of unemployed participants) or gaining support from living with others (79% of employed participants; 69% of unemployed participants). Other environmental factors such as physical aspects of the environment, attitudes of other people and the systems, services and policies that may influence employment were also examined. Participants reported experiencing few barriers in the natural and humanmade environments, few incidents of attitudinal barriers and did not report significant difficulties with existing services, systems and policies. Differences between the employed and unemployed groups on the CHIEF-SF domains of Physical/structural, Policies and Attitudes & Support negligible.

Facilitators and barriers to employment Participants rated their top three facilitators or barriers to resuming employment depending on whether they were employed or unemployed. These were mapped to the ICF framework using previously published ICF linking rules (Cieza et al., 2002, 2005). This study intended to evaluate the impact of contextual factors, focusing on environmental factors; however the most commonly cited facilitatory factor was the personal factor – motivation. This was followed by environmental factors such as support of partner/family and friends (e310/e320), the support of employers and/or colleagues (e325/e330) and the type of industry/role a person was engaged in (e590) (Table 4). This suggests that employed participants feel a strong sense of personal motivation to work towards specific goals and also report benefits from environmental factors. The most common barrier to employment was being unable to return to pre-injury employment due to disability and the person perceiving their skills to be nontransferrable to another area of employment. This barrier mapped to the environmental factor: e590 Labour and employment services, systems and policies, which is also a facilitator as noted above. Difficulties accessing the physical work environment was another environmental barrier (e150) reported by unemployed participants. Health issues limiting return to work was the only barrier identified from the ICF domain of body functions. Examples provided by participants focussed on pain (b280) and mood (b126).

Discussion This paper reported on a cross-sectional cohort study examining the employment of 30 participants with a dual diagnosis of SCI and TBI, discharged within the last five years from a single rehabilitation unit. The study aimed to examine the contextual factors that supported employment of people with a dual diagnosis primarily focusing on external environmental factors. The

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TABLE 1: Demographic, injury related and rehabilitation group comparison Employed n = 14 Demographic variables Sex: n male:female Age at injury years: mean (SD) Education years: median (IQR) Primary/Secondary Trade/Tertiary Relationship status at injury: n (%) Married/Cohabitation Single/Separated SCI severity ASIA: n (%) A B C D SCI level: n (%) Cervical Thoracic Lumbar TBI severity PTA range: n (%) Mild-moderate (29 days) GCS range: n (%)* 3–8 9–12 13–15 Rehabilitation variables Length of stay days: mean (SD) Admission total FIMTM: mean (SD) Discharge total FIMTM: mean (SD) Interview variables Time from discharge to interview years: mean (SD) Currently lives with: n (%) Alone With others Current relationship status: n (%) Married/Cohabitation Single/Separated Current FIMTM: mean (SD)

11:3 36.5 (12.6) 12 (2) 1.5 (3.3) 9 (64) 5 (36)

Unemployed n = 16

t

15:1 41.8 (13.7) 10 (2) 2.5 (3)

v2

P

1.5 1.1

0.22 0.29

1.5 0.4

0.17 0.76 2.1

0.14

(44) (6) (25) (25)

2.2

0.53

4 (29) 8 (57) 2 (14)

6 (38) 8 (50) 2 (13)

0.3

0.88

3 (21) 9 (64) 2 (14)

5 (31) 8 (50) 3 (19)

0.6

0.73

3 (21) 1 (7) 10 (71)

1 (6) 2 (13) 10 (63)

1.3

0.52

132 (58) 76.5 (22.0) 98.1 (19.5)

162 (81) 71.6 (18.8) 96.2 (23.0)

1.1 0.6 0.2

0.27 0.51 0.81

3.0 (1.8)

3.6 (2.2)

0.8

0.41

3 (21) 11 (79)

5 (31) 11 (69)

0.4

0.54

8 (57) 6 (43) 108.6 (19.2)

6 (38) 10 (63) 98.8 (23.1)

1.2

0.28

8 2 1 3

(57) (14) (7) (21)

6 (38) 10 (63)

7 1 4 4

1.3

0.22

*GCS data available for 27 participants. ASIA, American Spinal Injury Association level; FIMTM, functional independence measure (range 18–126); GCS, Glasgow Coma Scale; IQR, inter-quartile range; PTA, post-traumatic amnesia; SCI, spinal cord injury; SD, standard deviation.

ICF framework was used to define environmental factors in terms of the natural and human-made environment (physical), support and relationships (social

environment) and attitudes, services, systems and policies (attitudinal environment). During this exploration, factors arose that were not considered external © 2014 Occupational Therapy Australia

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TABLE 2: Job categories at injury and interview ASCO major group 1 2/3 4/9

5/6/8

7

ASCO description Managers and administrators Professionals and Associate professionals Tradespersons/ Labourers and related workers Advanced/Intermediate/ Elementary clerical, sales and service workers Intermediate production and transport workers

Job at injury n = 27

Job at interview n = 14

3

2

7

5

9

2

3

3

5

2

ASCO, Australian Standard Classification of Occupations.

TABLE 3: Differences between employed and unemployed participants groups related to external environmental factors Employed n = 14

Unemployed n = 16

Interpersonal relationships: median (IQR) 20.5 (6) 18.0 (8) SPRS Part B: Relationships (ICF codes e310/e320/e325/ d310/d330/d350) Physical environment: median (IQR) 1.5 (2.5) 1.8 (3.5) CHIEF-SF Physical/ structural (ICF codes e210/e215/ e225/e240/e250) Attitudinal environment: median (IQR) 0.0 (0.6) 0.0 (0.5) CHIEF-SF policies (ICF codes e520/e540/ e570/e580) 0.0 (0.5) 0.0 (0.0) CHIEF-SF Work/ school (ICF codes e585/e590/ e425/e430) 0.5 (1.3) 0.0 (0.5) CHIEF-SF Attitudes/Support (ICF codes e410/ e415/e420/e440/ e445/e460)

© 2014 Occupational Therapy Australia

Z

P

0.98

0.33

0.65

0.50

0.17

0.86

0.98

0.33

0.98

0.34

environmental factors. These factors represented internal personal factors that influenced employment outcomes. The level of employment (47%) in this dual diagnosis cohort was within the middle range of previously reported single diagnosis studies of SCI 21–67% (Lidal, Huynh & Biering-Sorensen, 2007) and TBI 10–70% (Yasuda, Wehman, Targett, Cifu & West, 2001). Several personal factors, including level of education, age, gender, severity of injury or time because injury, did not appear to influence return to paid employment in this dual diagnosis cohort. These factors have been previously identified at potential mediators of return to work in adults with SCI (Anderson et al., 2007). Three significant findings emerged from this research. First, all participants reported a high level of interpersonal support and reported experiencing few physical or attitudinal barriers in their day to day lives. Second, there were no statistically significant differences in the social, physical or attitudinal supports/barriers experienced by the employed and unemployed subgroups. Third, the most common facilitator of employment identified by participants was personal motivation. These results have implications for the rehabilitation of people with a dual diagnosis of SCI/TBI. The level of social support experienced by participants in this study was indexed using the SPRS Part B (Relationships) score and the CHIEF domain of Attitudes and Support. Participants reported highly supportive interpersonal relationships with close family, friends and colleagues. Support of family and friends was the second highest endorsed facilitator of return to work, with ten of the 14 employed participants identifying this as a facilitator. Even though supportive relationships were subjectively reported to facilitate return to work, the level of support experienced by employed and unemployed participants (based on objective scales) was similar, suggesting that it may be an important contextual factor but perhaps not a differentiating factor. Higher scores on community integration and social support measures have previously been correlated with greater levels of productive engagement both for people with single diagnosis SCI (Anderson et al., 2007; Murphy et al., 2009, 2011) and TBI (Wagner et al., 2002). Interventions focussing on the social environment such as peer mentoring (Veith, Sherman & Pellino, 2006) and social network interventions (Rauch & Ferry, 2001) have also been shown to positively affect the social engagement and quality of life of people with SCI and TBI. Further research is needed to determine if strengthening the social supports of a person with a DDx may enhance their employment outcome. In the light of the endorsement of social support in facilitating employment of individuals who have a DDx, research is also required to address questions such as ‘What specific

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TABLE 4: Facilitators and barriers to employment linked to ICF codes Facilitators/Barriers to employment Facilitators of resuming employment (n = 14) My own personal motivation (b130) The support of my partner/family and friends (e310/e320) Supportive attitude of my employer and/or work colleagues (e325/e330) The type of industry, work role or flexible duties (e590) Barriers to resuming employment (n = 16) My disability prevents return to pre-injury employment and my skills are not transferable (e590) Health issues prevent me from holding a job (b280/b126) Difficulties with physical access/work environment/conditions (e150) Active involvement in study, vocational training or rehabilitation (d825/e590) Retired

n

13 10 8 7

8

8 6 2 2

aspects of social support encourage increased employment?’ and ‘Is it the practical support or the effect this support has on a person’s internal motivation that makes a difference?’ Interestingly, employed and unemployed adults with DDx experienced similar levels of physical and attitudinal barriers in the community. Furthermore, the degree to which these barriers impacted our participants was on average very low. This is in contrast with previous research which has found that reducing physical and attitudinal barriers can have a significant positive impact on the employment of people with single diagnoses SCI (Anderson et al., 2007; Jongbloed et al., 2007; Murphy et al., 2011; Noreau et al., 1999) or TBI (Whiteneck, Gerhart, et al., 2004). Aspects of these work environments such as flexible hours and the absence of physical access barriers have previously been found to support employment (Jongbloed et al.; Whiteneck, Gerhart, et al.). The extent to which these factors impact on employment of people with a DDx in Australia requires further examination, particularly as employed participants endorsed supportive employer attitudes and work role/flexible duties as the third and fourth most supportive factors to resuming employment. Further research is needed to examine current support provisions in physical and attitudinal environments, particularly their timing, impact on employment and influence on the overall functioning of people with a DDx. Current return to work programmes emphasise

the physical job demands and modification of physical barriers (Hart et al., 2010). The findings of this article suggest that return to work could be further enhanced by addressing the attitudinal and social environments of people with DDx. Possibly the greatest insight into critical factors supporting the employment of people with a DDx came from the self-report of ‘own personal motivation’ as the most common contextual factor to facilitate employment. Other domains of health such as Body Functions and Activity (e.g. injury severity and functional ability) were not different between the employed and unemployed groups; however, the most common reason reported for unemployment was ‘my disability prevents return to pre-injury employment’. This suggests that although the two groups had similar functional abilities, the way they perceived their abilities and their internal resources, such as motivation, significantly affected their employment. This finding is supported by previous research identifying that the coping skills of people with brain injuries impacts their employment (Macaden, Chandler, Chandler & Berry, 2010). White, Driver and Warren (2008) also recognise the need for interventions which foster the development of resilience, but acknowledge the lack of research in this area. The current research aimed to primarily examine the external environmental factors that impact on the employment of people with DDx, therefore exploration of personal factors (such as motivation) was beyond the study scope, however, these findings suggest that attention should be given to building the internal resources of people with DDx when aiming towards employment. This study had several limitations. First, the small sample size and recruitment from a single rehabilitation facility limits the generalisation of findings to the wider DDx population. However, the sample was widely representative in terms of injury severity and ASIA level and was drawn from a state-wide rehabilitation facility. The state-wide nature of the service limited ability to follow-up many potential participants who had been discharged to regional areas and were no longer in contact with the service provider. The low response rate was primarily due to potential participants citing lack of time or conflicting commitments, or potential participants were unable to be contacted due to out of date contact details. The resulting cohort may therefore be biased towards those who are coping well, with higher levels of support from family and health services. There are few existing DDx studies, and this study provides valuable insight into the factors which support the employment of people with DDx. Further research is needed into this area using a greater number of participants from more rehabilitation settings. Comparison between DDx and single diagnosis SCI and TBI is also warranted, as the compound effect of both diagnoses has received minimal study. There is currently no ‘gold © 2014 Occupational Therapy Australia

342 standard’ for assessing the multi-factorial concepts this study investigated. There were limitations in using each of the standardised assessments for the purposes of this study. None of the tools used required participants to answer questions relating to vocational rehabilitation or financial considerations, which have been previously shown to impact employment (Jongbloed et al., 2007). The CHIEF-SF investigates the presence of environmental barriers without providing the detail required to address specific problems (Whiteneck, Harrison-Felix, et al., 2004) while the scoring system allows for some ongoing problems to appear insignificant if they occur less than monthly or a person does not work. The VQ asks separate questions for people who are employed and those who are not. This limits the ability to compare the two groups in terms of the factors influencing their employment status. Neither the CHIEF-SF nor the SPRS include any questions related to employer support. The SPRS includes items that do not apply to all participants which can skew results. The rating scale used can also be a source of confusion as there are multiple response options (Tate et al., 1999). While the assessments used each have limitations, they were implemented in a standardised manner by a trained research health professional, and have provided a starting point for identifying contextual factors which influence employment status.

Conclusion Adults with dual diagnosis who participated in this study experienced few physical or attitudinal barriers in their day to day lives, and reported highly supportive interpersonal relationships with close family and friends. Even though supportive relationships were subjectively reported to facilitate return to work, the level of support experienced by employed and unemployed participants was similar, suggesting that it may be an important contextual factor but perhaps not a differentiating factor in determining work outcomes. The most frequently reported contextual factor that facilitated resumption of paid work, was personal motivation. Further research is required to investigate specific interventions that could be used by rehabilitation specialists to strengthen contextual factors, particularly personal factors, to support the employment of adults with dual diagnosis SCI/TBI.

Acknowledgements We would like to acknowledge Dr Andrew Jones and Hannah Barden who were consultants on this project and conducted many of the interviews. The authors gratefully acknowledge the Lifetime Care and Support Scheme (NSW) for funding this project. Project No: 08/212.

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