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Inclusive employment: understanding the barriers to and facilitators of employment for persons with mental disability in East Africa Ikenna D. Ebuenyi
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Inclusive employment: understanding the barriers to and facilitators of employment for persons with mental disability
in East Africa
Ikenna D. Ebuenyi
Inclusive employment: understanding the barriers to and facilitators of employment for persons with mental disability
in East Africa
Ikenna D. Ebuenyi
Colofon
Members of the thesis committee:
prof. dr. Jacqueline Broerse
prof. dr. Geert Van Hove
prof. dr. Michael Stein,
prof. dr. Pamela Wright
dr. Silvia Alemany
dr. Teun Zuiderent-Jerak
ISBN: 978-94-028-1687-7
©2019 I.D. Ebuenyi
All right reserved. No part of this work may be reproduced by print, photocopy or other means
without any written permission of the author.
VRIJE UNIVERSITEIT
Inclusive employment: understanding the barriers to and facilitators of employment for persons with mental disability
in East Africa
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad Doctor of Philosophy
aan de Vrije Universiteit Amsterdam en de Universitat de Barcelona,
op gezag van de rectores magnifici
prof.dr. V. Subramaniam en prof.dr. J.E. García,
in het openbaar te verdedigen
ten overstaan van de promotiecommissie
van de Faculteit der Bètawetenschappen
op maandag 28 oktober 2019 om 11.45 uur
in het auditorium van de universiteit,
De Boelelaan 1105
door
Ikenna Desmond Ebuenyi
geboren te Owerri, Nigeria
promotoren: prof. dr. J.F.G. Bunders
dr. M. Guxens
copromotor: dr. B.J. Regeer
Dit proefschrift is tot stand gekomen in het kader van het Erasmus Mundus program of the
European Union for International Doctorate in Transdisciplinary Global Health Solutions (Specific
Grant Agreement 2016-1346), onder toezicht van een samenwerkingsverband bestaande uit:
Instituto de Salud Global de Barcelona (ISGlobal) van de Universitat de Barcelona, Spanje; en
Athena Instituut, Vrije Universiteit Amsterdam, Nederland;
This thesis has been written within the framework of the Erasmus Mundus program of the
European Union for International Doctorate in Transdisciplinary Global Health Solutions (Specific
Grant Agreement 2016-1346), under the joint supervision of the following partners: Instituto de
Salud Global de Barcelona (ISGlobal), Universitat de Barcelona, Spain; and Athena Institute, VU
University, Amsterdam The Netherlands.
Author
Ikenna D. Ebuenyi
Layout
Floor Vogels
Cover design
Ododo Avwerosuo
The study was completed within the Erasmus Mundus Joint Doctorate Program of the European
Union for International Doctorate in Transdisciplinary Global Health Solutions; a consortium
consisting of:
• Institute of Tropical Medicine, Antwerp, Belgium
• VU University Amsterdam, Amsterdam, The Netherlands
• University of Barcelona, Barcelona, Spain
• Universiteit van Amsterdam, Amsterdam, The Netherlands
• Academisch Medisch Centrum bij de Universiteit van Amsterdam, Amsterdam, The
Netherlands
• Université de Bordeaux, Bordeaux, France
Funding was from the Erasmus Mundus Joint Doctorate Program of the European Union (Specific
Grant Agreement 2016-1346).
In loving memory of Theophilus Ebuenyi-father, teacher and friend&To all with psychosocial disabilities
CONTENTS Account 9 Chapter 1 Introduction 11 Chapter 2 Theoretical framework 19 Chapter 3 Research design 27 Chapter 4 Barriers to and facilitators of employment for people with
psychiatric disabilities in Africa: A scoping review 47 Chapter 5 Legal and policy provisions for reasonable accommodation in
employment of persons with mental disability in East Africa:
A review 75 Chapter 6 Employability of persons with mental disability: understanding
lived experiences in Kenya 93 Chapter 7 Experienced and anticipated discrimination and social functioning
in persons with mental disabilities in Kenya: implications for
employment 121 Chapter 8 Expectations Management; employer perspectives on opportunities
for improved employment of persons with mental disabilities
in Kenya. 143 Chapter 9 Perspectives of mental healthcare providers on pathways to
improved employment for persons with mental disability in two
lower middle-income countries 167 Chapter 10 Challenges of inclusion: A qualitative study exploring barriers and
pathways to inclusion of people mental with disability in technical
and vocational education and training programmes in East Africa. 189 Chapter 11 Stakeholder reflection on the results 211 Chapter 12 Discussion and conclusion 225
8
Summary 246Acknowledgements 250About the author 253
9
ACCOUNTChapters 4 to 10 of the thesis are based on articles that are published or under review in peer-
reviewed journals.
Chapter 4Ebuenyi ID, Syurina EV, Bunders JF, Regeer BJ. Barriers to and facilitators of employment for people
with psychiatric disabilities in Africa: a scoping review. Global health action. 2018;11(1):1463658.
Chapter 5Ebuenyi ID, Regeer BJ, Nthenge M, Nardodkar R, Waltz M, Bunders-Aelen JF. Legal and policy
provisions for reasonable accommodation in employment of persons with mental disability in East
Africa: A review. International Journal of Law and Psychiatry. 2019 May 1;64:99-105.
Chapter 6Ebuenyi ID, Guxens M, Ombati E, Bunders-Aelen JFG, Regeer BJ. Employability of Persons
With Mental Disability: Understanding Lived Experiences in Kenya. Frontiers in Psychiatry.
2019;10(539).
Chapter 7Ebuenyi ID, Regeer BJ, Ndetei DM, Bunders-Aelen JF, Guxens M. Experienced and anticipated
discrimination and social functioning in persons with mental disabilities in Kenya: implications for
employment. Frontiers in Psychiatry. 2019;10:181.
Chapter 8Ebuenyi ID, van der Ham AJ, Bunders-Aelen JFG, Regeer BJ. Expectations management; employer
perspectives on opportunities for improved employment of persons with mental disabilities in
Kenya. Disability and rehabilitation. 2019:1-10.
Chapter 9Ebuenyi ID, Regeer BJ Bunders JF, Aguocha C, Guxens M. Perspectives of mental health care
providers on pathways to improved employment for persons with mental disability in two lower
middle-income countries. International Journal of Mental Health Systems [Under review].
Chapter 10Ebuenyi I D, S. Rottenburg E, Bunders-Aelen JF, Regeer BJ. Challenges of inclusion: a qualitative
study exploring barriers and pathways to inclusion of persons with mental disabilities in technical
and vocational education and training programmes in East Africa. Disability and rehabilitation. 2018
Sep 22:1-9.
C H A P T E R 1 INTRODUCTION
C H A P T E R 1 INTRODUCTION
CHAPTER 1
12
1. INTRODUCTION
No one would ever say that someone with a broken arm or a broken leg is less than a whole
person, but people say that or imply that all the time about people with mental llness.
– Elyn Saks
1.1. Problem statement
The above statement on living with schizophrenia by Elyn Saks,a US Professor of Law, encapsulates
the prevailing perceptions of, and attitudes towards, mental illness. Mental illness is often
misunderstood and feared, and historically, persons with mental illness have been treated differently
from other individuals [1]. Society as a whole, along with its institutions, policies, and codes, metes
out this differential treatment, meaning that those with mental illness suffer social exclusion and
deprivation [2, 3]. Essentially, mental illness is perceived as socially unacceptable [4, 5]. Depending
on the onset and social setting, mental illness may lead to educational deprivation which also reduces
employment opportunities if educational certificates are required. If the onset of mental illness
comes later, the individual may have an education but still be unable to obtain employment due to
stigma, lack of jobs, or because they lack the resources to become self-employed [6].
Employment is a key element of wellbeing and quality of life [7]. This is not only because it provides
a livelihood but also because it serves as a means of self-identification and participation [8]. Work
was mainly an individual construct before the advent of corporations and white-collar jobs [9].
Now, work is becoming more specialised and skill-based professions are increasing exponentially
[9]. This changes the shape of the job market: while increasing specialisation is creating more jobs,
capital is not equally distributed, jobs are not uniformly accessible to everyone everywhere, ever
higher levels of education are required and competition is enormous [10, 11]. As a result, people
are left behind and wanting. Fewer jobs increase the competition for available jobs and the burden
of choice for employers. The need for productivity, profit and perfection means that those who
are perceived to be unfit for the demands of the job are not recruited. Employers everywhere
select on the basis of specific criteria including education, personal qualities and health [12]. It is
on the basis of these perceptions that pre-employment assessment is widely adopted as a means
of selection and hiring. While its proponents argue in its favour, studies suggest that it poses a
major limitation for persons with disabilities. Although pre-employment assessment is said to help
employers understand and decide on making reasonable workplace accommodation, for persons
with mental illness it may eliminate the chances of employment [13].
Persons with mental illness face a number of significant hurdles when seeking employment. Long-
term illness, lack of skills or education, and social exclusion or stigma on the part of employers are
major factors limiting the individual’s opportunities [14]. These factors may explain the dismal rates
of employment of persons with a mental disability compared to the general population. According
to OECD’s 2010 report, even in high-income countries, which have various supported employment
Introduction
13
1
schemes and social security systems, only about one in four persons with mental disability who
are seeking employment are in work [15]. Furthermore, studies suggest that their conditions of
employment are often worse than among the general economically active population [16, 17].
For instance, they are more likely to be in low-paid work or accept jobs below their education and
qualifications [6]. In low-income settings, such as in African countries, where support systems are
scarce if not absent, unemployment rates are even more dismal. As a result, persons with mental
illness are more likely to be living in dire poverty, often with no consistent source of income or
possibility of employment.
Several studies have identified the two-way relationship between poverty and mental illness
[2, 18, 19]. The inequality experienced by persons with a mental illness in obtaining access to
education, health services, employment and indeed all spheres of life have been the subject of
several research studies. The treatment gap for mental illness is estimated to be as high as 80%
in some parts of the world [20, 21]. In low-income countries like Kenya, factors relating to stigma,
cultural perceptions of mental illness and health-system problems place persons with mental
illness at a huge disadvantage [22-24]. These inequities have implications for an individual’s
ability to work and obtain access to formal employment because, as Lund and colleagues
described, they entrench inequality and the social restriction faced by persons with mental
illness [2]. In fact, the lack of work for persons with mental illness also affects their recovery
[25], while there is also evidence of a positive correlation between the acceptance of mental
illness as a ‘disability’ and employment opportunities. Under the rubric of disability, it has been
possible for individuals with mental illness to receive reasonable accommodation in employment
[26]. One of the aims of this study is to explore this relationship between mental illness as
‘disability’ and employability in the context of Kenya. The overall aim of the study is to identify
factors influencing the employability of persons with mental disability in Kenya.
1.2 Mental illness as a disability, employment and the global context
The rights of persons with mental disabilities
The United Nations Convention on the Rights of Persons with Disabilities (CRPD) was adopted by
the United Nations General Assembly in 2006. Since its initiation in 2007, over 177 countries have
signed and ratified it [27]. Article 1 articulates the purpose of the Convention which is ‘to promote,
protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by
all persons with disabilities, and to promote respect for their inherent dignity’. This Article also sets
out an inclusive definition of disability which includes all persons ‘with long term physical, mental,
intellectual and sensory impairments, which in interaction with various barriers may hinder
their full and effective participation in society on an equal basis with others’ [28].
Based on this definition, any mental illness that affects an individual’s social and occupational
functioning is considered to be a disability. The global burden of disease has identified depression
as one of the leading causes of disability [29, 30]. Severe forms of mental illness that affect
social and occupational functioning are regarded as sources of disability or termed mental/
CHAPTER 1
14
psychiatric disabilities [31]. In spite of this, the acceptance of mental illness as disabling is not
universal and even in countries that have ratified the CRPD, persons with mental disabilities
experience social exclusion, and may be denied reasonable accommodation in education and
employment [26] and equal access to social benefits [32]. Reports have noted national and
regional differences between the ratification of the CRPD and implementation of policies that
promote its objectives [33, 34]. Hence, the perception and acceptance of mental illness as a
disability may vary depending on the setting and severity of illness and with various implications
for employment and access to services [19, 35].
Employment and recovery
The importance of employment for recovery has been extensively studied. Studies across the
world, in low-, middle- and high-income countries (LICs, MICs, HICs) have shown that financial
independence and economic stability are key factors in individuals’ mental and physical wellbeing
[12, 36]. The concept of psychiatric rehabilitation, which is exemplified by schemes like care farms
[37] and supported employment [38], derives from the belief that persons with mental illness
can work and should work. Studies have also shown that with the right form of support persons
with a mental disability are able to work [38, 39]. These concepts have been demonstrated in
several HICs. In the US, for example, Burns and colleagues demonstrated through an randomised
controlled trial (RCT) that supported employment can help [38]. In this study, it was shown that
individual placement and support (IPS) was an effective approach for vocational rehabilitation for
persons with severe mental illness. Zhang and colleagues working in China have also demonstrated
in an RCT that integrated supported employment (ISE) was relevant for employment of persons
with schizophrenia [40]. Employment ensures that the individual is able to earn a living and
participate independently in society, and also contributes to reducing stigma reduction by
dethroning myths that persons with mental illness are unable to work.
Despite the promising results from vocational rehabilitation schemes for persons with mental
illness in HICs, there are few studies in African countries on employment rates for persons with
mental disability. LICs in Africa and elsewhere are characterised by massive unemployment and
also by cultural beliefs about the aetiology and nature of mental illness. In many countries in Africa,
employment is largely informal. According to the International Labour Organization (ILO), 2 billion
people work informally and 93% of global informal employment is in emerging economic powers
and low- and middle-income countries (LMICs). Throughout Africa, 85.8% of employment is
informal [41]. Informal employment is more vulnerable to exploitation and lacks any of the benefit
schemes and support structures that might be available in the formal economy. Moreover, there
are few social welfare packages and a general lack of universal health coverage [12]. Hence, the
impact of unemployment on the lives of persons with mental disabilities has both economic and
health implications. The economic deprivation of persons with mental disability in Africa led to
recent calls for global mental health funds for severe mental illness in LMICs [42]. There is also lack
of data and research on pathways to employment for persons with mental disabilities in African
countries, where few studies have explored the factors that influence employment for persons
with mental disabilities.
Introduction
15
1
In this PhD thesis, we will explore the factors that influence employment for persons with mental
disabilities. We have used several terms such as mental, psychiatric and psychosocial disability to
refer to mental illness. This is not intended to create confusion but to highlight the complexity of
the terms and the different hats a researcher on the subject may be asked to wear. Individuals from
a professional health background tend to use the terms ‘mental’ or ‘psychiatric disabilities/
illness’, but those working from a rights perspective prefer ‘psychosocial disabilities’, which is less
stigmatising. Are these different conditions? I dare say not; but the choice of term is the individual’s
just as we all opt for how we identify ourselves.
1.3 Mental illness and employment in Kenya
In Kenya, the detection rate for mental disorders is about 4.1% and there is little care available
for persons with mental illness [43] The outcome and quality of life of persons with mental illness
is poor owing both to health-system and socio-political factors [24, 44, 45]. There is a dearth of
basic mental health services, and government funding for mental health care is less than 1% of the
total health budget [24, 46]. Access to mental health services is affected by factors such as high
cost, distance of health services, and shortage of mental health professionals. There are only about
100 psychiatrists for a population of 46 million people. Mental health services in Kenya are mainly
offered by psychiatric nurses, community health workers (CHWs) and traditional healers [47]. These
services usually operate on an outpatient basis; inpatient mental health care services are scarce.
Mathare referral hospital is the main psychiatric centre in the country and its use is limited by both
sub-optimal services and the heightened stigma associated with using its services.
The Kenyan National Commission on Human Rights (KNCHR) reports that ‘there is entrenched
stigma against mental illness and persons with mental disorders’ [24], rooted in cultural beliefs
and perceptions about mental illness. The attribution of mental illness to a curse or the belief
that it is caused by drug use is pervasive, and continues to have adverse implications for the
social and occupational functioning of persons with mental illness in Kenya [48].
Employment conditions of persons with mental illness in Kenya
According to the Kenyan national survey of persons with disabilities, the prevalence of mental
disabilities in Kenya is 5.8%. One in three persons with disabilities in Kenya work in their
family business while one third do not work at all [49]. However, a according to a more recent
report from the concluding observations of the CRPD committee Kenya, only 1% of persons
with disabilities are employed [50] compared to 88.5% among the general population [51].
This employment gap is very glaring, with particularly dire implications for the socioeconomic
lives of persons with mental disabilities.
Research on the experience of employment among persons with mental disabilities in Kenya is
scarce. Although studies have explored the stigma associated with mental illness [1, 23, 52], we are
unaware of any study that has explored its relationship with employment. We do not yet know what
factors would significantly improve employment for persons with mental disabilities in Kenya.
CHAPTER 1
16
The aim of this thesis is to address this gap, and identify factors influencing the employability of
persons with mental disability in Kenya. In some of the studies, we extended the scope of the study
to East Africa, and across Africa, in our literature review. The study adopts a transdisciplinary
approach informed by the understanding of the complexity of mental disability in relation to
employment. In this thesis, I intend to untangle the challenges that persons with mental illness face
in seeking employment and identity factors that may improve their employability.
Introduction
17
1
C H A P T E R 2 THEORETICAL FRAMEWORK
CHAPTER 2
20
2. THEORETICAL FRAMEWORK There is only one way to look at things, until someone shows us how to look at them with different
eyes. – Pablo Picasso
In this chapter we describe the core concepts that underpin this research. We intend to explore
the concept of mental illness as a source of disability, and the rights of persons with mental illness
to fulfil the basic needs of life and be free from all forms of discrimination. In order to understand
the barriers to and facilitators of employment for persons with mental disabilities, we used four
models: the rights-based model that undergirds the CRPD; the social inclusion and recovery
model; the bio-psychosocial model of the International Classification of Functioning, Disability
and Health (ICF); and the socio-ecological model. The models provided us with sensitising
concepts that informed our study [53] and are central to the relationship between mental illness
and employment: the concept of employment as a human right; social inclusion and recovery in
mental illness; the definition of mental illness as disability; and a framework of the factors that
affect employment. The following sections attempt to provide more insight into these theories
and their relation to employment for persons with mental disability.
2.1 The rights-based model of disability
Inclusive employment is a human right and persons with mental disability have the right to
employment as enshrined in the CRPD [28]. Equity and social justice require governments
and employers to ensure equal employment opportunities for persons with mental disability
without discriminating on the basis of illness [12]. This notion is supported by the rights-based
model of disability as espoused by the CRPD [28]. The World Health Organization (WHO) and
CRPD view employment as a human right for persons with disability and recommend reasonable
accommodation for them by state parties and all signatories to the CRPD. In this study, using the
rights-based model as a framework, we argue that mental illness is a disability and that persons
with mental disabilities have the right to education and employment as well as freedom from
discrimination in obtaining and retaining employment.
The CPRD represents a shift from the medical and social model of disability to a rights-based
perspective. This perspective is highlighted in Article 1 of the convention which declares that its
purpose ‘is to promote, protect and ensure the full and equal enjoyment of all human rights and
fundamental freedoms by all persons with disabilities, and to promote respect for their inherent
dignity’ [28]. This leads to an inclusive definition of disability that includes persons with mental
illness. In subsequent articles of the CRPD, persons with disabilities are viewed as rights-holders
and not people who are sick and in need of charity from society and governments [54]. Governments
or State parties are identified as duty-bearers in the recommendations for the realisation of
the fundamental human rights of persons with disabilities.
Theoretical framework
21
2
Articles 24, 25, 26 and 27 of the CRPD elaborate the rights to education, health, habilitation and
rehabilitation, and work and employment respectively, which in addition to other rights espoused in
the CRPD, are particularly relevant for employment of persons with mental disabilities. Recognising
the social disadvantages associated with disabilities, the rights-based model recommends that
governments everywhere protect these basic rights for persons with disabilities. Kenya signed
the CRPD in 2007 and ratified it in 2008. In 2014, the Government of Kenya (GoK) submitted its
Initial State Party report to the Committee on the Rights of Persons with Disabilities [50].
2.2. Social Inclusion and Recovery in Mental illness
Implicit in the rights-based model is the social inclusion and recovery perspective in mental illness that
perceive the right to employment as both relevant to social inclusion and recovery [7]. Social inclusion
may be defined as ‘a virtuous circle of improved rights of access to the social and economic world,
new opportunities, recovery of status and meaning and reduced impact of disability’ [55].
Social inclusion and participation in society are important and integral conditions for personal
recovery in mental illness [56]. The social exclusion of persons with mental illness leads to social,
physical, psychological and occupational deprivation, with grave implications for recovery [7, 56,
57]. Social exclusion could emanate from family, employers, society, and mental health workers
who often may not understand the needs of the individual and view them only from the lens of the
diagnosis [56, 58].
These disadvantages foster dependency and have implications for employment, which is
considered useful for recovery in mental illness. Unemployment has a severe impact on mental
illness as it not only increases poverty but also erodes self-esteem and identity [7, 56, 58]. Hence,
Repper and Perkins recommend promoting the inclusion of persons with mental illness to reduce
their experience of disability [58]. In this study, we intend to explore social inclusion and support of
persons with mental illness in not only the work environment but also in other areas of life such as
education and health.
WHO recommends competitive employment through Individual Placement and Support (IPS) for
the employment of persons with severe mental illness [59]. National- and context-specific inclusive
employment pathways to improve employability are essential for equity, social justice and improved
quality of life of persons with mental disability, and for reducing the global burden of disability.
However, these recommendations are impossible in settings that lack institutionalised mechanisms
for the social inclusion of persons with mental disabilities. Therefore, in this study we also adopt
the social inclusion and recovery model of mental illness [58], which recommends inclusiveness for
persons with mental illness to foster ‘personal’ recovery and social reintegration.
CHAPTER 2
22
2.3 Bio-psychosocial model
The bio-psychosocial model of the International Classification of Functioning, Disability and
Health (ICF) [60] elaborates an all-inclusive model of disability. It identifies mental illness as a
source of disability and elaborates on the impact of the environmental factors on disability. The
ICF is a universal framework for defining disability [31, 61, 62] (Figure 2.1) and broadly classifies
disability into two factors: i) functioning and disability, and ii) contextual factors. Functioning and
disability includes all impairments in bodily function (e.g. psychological function) and structure
(physiological or anatomical), as well as those that limit an individual’s participation in activity.
Contextual factors refer to environmental factors (e.g. workplace, school, family, policies) and
personal factors that affect functioning and disability [62]. Hence, in defining disability, personal
and socio-environmental factors as well as the impairment in bodily structure and function are
considered as influencing how disability is perceived and its effect on the individual. Disability
thus encompasses impairment in psychological functions and is not limited to physical impairment
[31, 61]. The role of personal and socio-environmental factors in the aetiology and persistence
of mental disability is recognised in both the ICF and the CRPD [62].
Such a broad and inclusive definition of disability which contextualises the impairment in bodily
structure and function avoids the controversy associated with the narrow perspectives of the
social and medical models of disability [61, 63, 64]. In the social model, the impact of disability is
considered to be related to the social environment (e.g. discrimination), while in the medical model,
disability is perceived as an impairment in/of the individual [65]. While the medical model focuses
solely on impairment with little regard for the impact of the social environment, the social model
focuses exclusively on disability as a social problem, ignoring the impact of its biological basis. The
ICF, on the contrary, offers an opportunity to view disability from a broader lens.
Figure 2.1: The ICF Model of Disability
13
Such a broad and inclusive definition of disability which contextualises the impairment in
bodily structure and function avoids the controversy associated with the narrow perspectives of
the social and medical models of disability [61, 63, 64]. In the social model, the impact of
disability is considered to be related to the social environment (e.g. discrimination), while in
the medical model, disability is perceived as an impairment in/of the individual [65]. While the
medical model focuses solely on impairment with little regard for the impact of the social
environment, the social model focuses exclusively on disability as a social problem, ignoring
the impact of its biological basis. The ICF, on the contrary, offers an opportunity to view
disability from a broader lens.
Figure 1: The ICF Model of Disability
Taking up from the ICF, this research seeks to understand the realities of the interconnectedness
of all these perspectives and analytically resolve them. Hence, we intend to explore the
complexity of disability and apply the bio-psychosocial model to mental disability. We are
Theoretical framework
23
2
Taking up from the ICF, this research seeks to understand the realities of the interconnectedness
of all these perspectives and analytically resolve them. Hence, we intend to explore the complexity
of disability and apply the bio-psychosocial model to mental disability. We are primarily interested
in the complex real-life problems of persons with mental disabilities, and we intend to analyse and
suggest ways to address them.
2.4 The Socio-ecological Model
We used the socio-ecological model (SEM) to contextualise the various barriers and facilitators
of employment for persons with mental disability at different levels. SEM (Figure 2.2) [66]
conceptualises individual, organisational, cultural, and socio-political level factors as either limiting
or facilitating factors in human development. In disability discourse, socio-environmental factors
are perceived as critical for persons with disabilities in general [67, 68] and for persons with
mental disability in particular [69, 70]. The ecological approach to social inclusion in disability has
been adopted in disability studies to explain the complex interaction of factors at the individual,
organisational, cultural and socio-political levels [71, 72]. Simplican and colleagues’ (2015)
framework for ecological pathways to and from social inclusion elaborates the various factors a
person with mental disability may encounter in employment and in seeking employment.
15
Figure 2: Socio-ecological model [66]
All the models of disability highlight specific aspects of what persons with mental illness looking foremployment have to face in terms of barriers to and facilitators of employment. The models also offeran opportunity to view these factors from diverse perspectives.
Socio-political
Laws, legal enforcement,
government, helath system
Cultural
Family, friends, social
network
Organizational
Employers , coworkers
Individual
Self-esteem, Knowlede,
motivation
Figure 2.2: Socio-ecological model [66]
CHAPTER 2
24
At an individual level, factors specific to individuals with a disability may affect their access
to developmental opportunities, including work participation [73]. For instance, self-esteem,
knowledge and personal motivation are considered crucial in the uptake of training and
employment opportunities among persons with mental disabilities [74].
At the organisational level, enabling or disabling factors exist in formal (e.g. workplace, schools)
and informal (e.g. families) settings [71]. They encompass organisational factors that inform
policies, systems and behaviours of people in a group [75]. In vocational education, this would
include factors that influence the behaviour of teachers and peers (e.g. knowledge), and policies in
vocational schools that affect both learning and teacher training activities.
Cultural-level factors encompass both community and interpersonal factors; they relate both
to the values, beliefs and attitudes of individuals in communities and how these values affect
interpersonal behaviour and interactions with person with mental disability [74, 76] within the
family and the broader community. Cultural beliefs and practices relating to mental illness may
lead to stigma and discrimination and thus hinder access to developmental programmes [76].
At the socio-political level, enabling or disabling factors relate to laws, legal enforcement and
market factors beyond individual organisations. Factors such as policy and legislation on disability,
employment, and education systems are included and are seen as influencing social conceptions of
disability and accommodations for persons with disability [54, 67].
All the models of disability highlight specific aspects of what persons with mental illness looking for
employment have to face in terms of barriers to and facilitators of employment. The models also
offer an opportunity to view these factors from diverse perspectives.
25
2
Theoretical Framework
C H A P T E R 3 RESEARCH DESIGN
CHAPTER 3
28
3. RESEARCH DESIGN Are you a researcher or are you a patient? – Anonymous
This chapter presents the overall research approach and design and provides an overview of
the methodology that was adopted in each of the studies. The research aimed to identify factors
influencing employability for persons with mental disability in Kenya and to identify pathways to
improve this.
Hence, the study aims to answer the following research question:
What are the barriers to and facilitators of employability for persons with mental disability in
Kenya?
In this multi-stakeholder study, we sought to explore the views of different stakeholder groups in
understanding barriers to and facilitators of employment for persons with mental disabilities in
Kenya as well as the options that they see for improving the situation. In this chapter we will first
elaborate on the transdisciplinary research (TDR) approach that was adopted (section 3.1). Next,
we will introduce the different phases of the overall study and the different sub-studies for each
phase as well as the corresponding research questions (section 3.2). Section 3.3 will provide more
details on the methodology employed in the different studies and includes a discussion on validity
and ethical considerations.
3.1 Research approach: a transdisciplinary research project
We adopted a transdisciplinary research (TDR) approach, as this is characterised by the inclusion
of relevant stakeholders throughout the research process in order to co-create knowledge
required to respond to a complex social issue [77], such as the employability of persons with a
mental disability.
TDR is employed for complex social issues, both employability and mental disability. The principles
that appeared to be beneficial to the TDR process were: involving potential knowledge users from
the start; the emergent design process consisting of several plan–action–observation–reflection
cycles; integration of knowledge and perspectives and bringing different stakeholders’ groups
together through the adoption of dialogue methodology [77, 78].
An important characteristic of a TDR approach is its phased process depicted by the action–
learning spiral phases (Figure 3.1) of homogeneous/heterogeneous exploration of ideas [79, 80]. It
includes exploration of the research questions both with similar and different stakeholder groups.
Hence, in trying to understand what works in the employment of persons with mental disabilities in
Kenya we decided on the research agenda in consultation with all stakeholder groups. We adopted
Research design
29
3
3.2 Research design and research questions
Following an emergent design philosophy, the research was set up in phases (Figure 3.2)
allowing for iteration between different studies. Table 3.1 presents an overview of the research,
sub-research and study-level questions.
Phase 1: Exploration
In order to gain understanding of the problem field and understand potential barriers to and
facilitators of the inclusion of people with mental disability, exploratory interviews were held and
desk studies were conducted. A systematic scoping review was undertaken to synthesise existing
evidence in the scientific literature regarding barriers and promotors in Africa. The study set out
the Interactive Learning and Action (ILA) framework that recommends the active participation
of all stakeholders as an operationalisation for TDR [80]. This process democratises knowledge-
creation and ensures active participation and a multi-perspective assessment of social problems.
Hence, we avoided the pitfall of conducting research for its own sake but sought to undertake
research to inform change. This action–learning approach was adopted to ensure that the
knowledge generated feeds into implementable processes. The action–research approach was
adopted in all the phases of the study [79]. This was made possible through the collaboration with
Light for the World (LFTW) Netherlands, an international disability non-government organization
(NGO), which used the knowledge generated from the research in its employment programmes for
persons with psychosocial disabilities in East Africa.
Figure 3.1: Action–research spiral [79]
Reflect
Reflect
Reflect
Plan
Plan
Act
Act
Observe
Observe
CHAPTER 3
30
to focus on East Africa, but this was extended to the African continent because of the dearth of
research.
Furthermore, as the role of employers is essential in the employment of persons with mental
disability and as policy can play a role in this, a review of policy and legal documents was conducted
to review the compliance of East African countries with the recommendations of the CRPD of
reasonable accommodation in employment for persons with mental disabilities. Sub- research
questions are hence:
1. What is the evidence in the scientific literature regarding the barriers to and facilitators of
employment of persons with psychiatric disability in Africa?
2. To what extent have the recommendations of the CRPD regarding reasonable
accommodation for employment of persons with mental disabilities been translated into
policy in East Africa?
Figure 3.2: Study Outline
Research design
31
3
Phase 2: Exploration of barriers and facilitators perceived by different stakeholder groups (exploration
by multiple stakeholders)
In order to contextualise the literature and policy review, a multi-stakeholder consultation was
conducted, mostly in Kenya, to explore the perspectives of different stakeholders, including
persons with mental disabilities, (potential) employers, mental health care providers and mental
health/disabled persons’ organisations. This was done through semi-structured interviews, focus
group discussions (FGDs) and, for some of the stakeholder groups, surveys. In addition, field notes
from observations, support group meetings, workshops and informal conversations with various
stakeholders were used in this phase of the study. The corresponding sub-question that was
answered is:
3. What are perspectives on barriers to and facilitators of inclusion of persons with mental
disability in employment in Kenya according to persons with mental disabilities, (potential)
employers, mental health care providers and mental health/disabled persons’ organisations?
This sub-question gave rise to five study-level questions which sought to explore the perspectives
of each stakeholder group on barriers to and facilitators of employment for persons with mental
disability. The reason was to have a broad range of ideas and to analyse commonalities on the
pathways to change. We started with an in-depth exploration of the barriers and facilitators as
perceived by persons with lived experience. Study-level questions include:
3a. What are the lived experiences of persons with mental disabilities in Kenya regarding
employment? and
3b. To what extent does experienced and anticipated discrimination and social functioning
affect the employment of persons with mental disabilities in Kenya?
Next, we explore the perspectives of employers:
3c. What are the perspectives of employers regarding the employment of person with mental
disabilities in Kenya?
As both people with lived experience and employers emphasised the need for illness stability
and rehabilitation, mental health care providers may play an important role, hence their
perspectives are included:
3d. What are the perspectives of mental healthcare providers on barriers and pathways
to improved employment for persons with mental disability in Kenya and Nigeria?
Finally, as training and education are fundamental to employment, and people with a mental
disability may have missed out on educational opportunities on account of their illness, the
role of Technical and Vocational Education and Training (TVET) programmes in enhancing the
employability of people with a mental disability is very relevant:
CHAPTER 3
32
Tab
le 3
.1: O
verv
iew
of r
esea
rch
, su
b r
esea
rch
an
d s
tud
y le
vel q
ues
tio
ns
R
esea
rch
qu
esti
on
Su
b-r
esea
rch
qu
esti
on
s St
ud
y-le
vel q
ues
tio
ns
Wh
at a
re t
he
bar
rier
s to
an
d f
acili
tato
rs o
f em
plo
yab
ility
fo
r p
erso
ns
wit
h
men
tal
dis
abili
ty in
Ken
ya?
1. W
hat
is
the
evid
ence
in
sci
enti
fic
liter
atu
re r
egar
din
g
the
bar
rier
s to
an
d fa
cilit
ato
rs o
f em
plo
ymen
t o
f p
erso
ns
wit
h p
sych
iatr
ic d
isab
ility
in A
fric
a?
1. W
hat
is t
he
evid
ence
in s
cien
tifi
c lit
erat
ure
reg
ard
ing
the
barr
iers
an
d
faci
litat
ors
of e
mpl
oym
ent
of p
erso
ns
wit
h p
sych
iatr
ic d
isab
ility
in A
fric
a?
2.
To
wh
at e
xten
t h
ave
the
reco
mm
end
atio
ns
of
the
CR
PD
re
gard
ing
reas
on
able
ac
com
mo
dat
ion
fo
r
emp
loym
ent
of
per
son
s w
ith
men
tal
dis
abili
ties
bee
n
tran
slat
ed in
to p
olic
y in
Eas
t A
fric
a
2.
To
wh
at e
xten
t h
ave
the
reco
mm
end
atio
ns o
f th
e C
RP
D r
egar
din
g
reas
on
able
ac
com
mo
dat
ion
fo
r em
plo
ymen
t o
f p
erso
ns
wit
h
men
tal
dis
abili
ties
bee
n t
ran
slat
ed in
to p
olic
y in
Eas
t Afr
ica?
3. W
hat
are
per
spec
tive
s o
n b
arri
ers
to a
nd
faci
litat
ors
of
incl
usi
on
of p
erso
ns
wit
h m
enta
l dis
abili
ty in
em
plo
ymen
t
in K
enya
acc
ord
ing
to p
erso
ns
wit
h m
enta
l d
isab
iliti
es,
(po
ten
tial
) em
plo
yers
, men
tal
hea
lth
car
e pr
ovi
der
s an
d
men
tal h
ealt
h/d
isab
led
per
son
s’ o
rgan
isat
ion
s?
3a.
Wh
at a
re t
he
lived
exp
erie
nce
s o
f pe
rso
ns
wit
h m
enta
l d
isab
iliti
es in
K
enya
reg
ard
ing
emp
loym
ent?
3b
. To
wh
at e
xten
t d
oes
exp
erie
nce
d a
nd
an
tici
pat
ed d
iscr
imin
atio
n a
nd
soci
al
fun
ctio
nin
g af
fect
th
e em
plo
ymen
t o
f pe
rso
ns
wit
h
men
tal
dis
abili
ties
in K
enya
?
3c.
Wh
at a
re t
he
per
spec
tive
s o
f em
plo
yers
reg
ard
ing
the
emp
loym
ent
of
per
son
wit
h m
enta
l dis
abili
ties
in K
enya
?
3d
. Wh
at a
re th
e p
ersp
ecti
ves
of m
enta
l hea
lth
car
e pr
ovi
der
s o
n p
ath
way
s
to im
pro
ved
em
plo
ymen
t fo
r pe
rso
ns
wit
h m
enta
l dis
abili
ty in
Ken
ya a
nd
Nig
eria
?
3e.
Wh
at a
re t
he
chal
len
ges
of i
ncl
usio
n o
f per
son
s w
ith
men
tal d
isab
iliti
es
in T
VE
T p
rogr
amm
es in
Eas
t A
fric
a?
Research design
33
3
3e. What are the challenges of inclusion of persons with mental disabilities in Technical and
Vocational Education and Training (TVET) programmes in East Africa?
Phase 3: Stakeholders’ reflection on the results
After the second phase, in which the issue is explored from multiple perspectives, a next phase
entails the integration of perspectives, action planning and implementation. In the context of this
study, this third phase was commenced but not completed. The part of the third phase that was
conducted in the context of this study involved a Dissemination & Dialogue meeting in which
different stakeholders reflected on the results. Hence, in order to obtain stakeholder responses
to findings on pathways to improved employability for person with mental disabilities in Kenya,
a multistakeholders meeting, based on the Dialogue model [78], was conducted in Kenya. The
meeting adopted roundtable discussions to analyze the findings from the initial two phases and to
identify realistic pathways to change. It offered an opportunity for a heterogeneous exploration
of the research questions which followed from the homogenous exploration from the initial
phases according to specific stakeholder perspectives.
In the meeting, input from additional stakeholders such as family members and policy makers who
were not involved in the initial phase were included in the exploration of pathways to improved
employability for persons with mental disabilities. An attempt was made to evaluate the findings
from first and second phase of the research with the stakeholders and identify pathways to
change through reflection on the results with stakeholders. The dialogue session helped to
holistically explore the resources needed, important actors and the preconditions to achieve
the change. A preliminary analysis is presented in this thesis.
3.3 Methods
This section describes the study setting and population, the method of data collection and
analysis for all the studies.
Study Setting and Population
Kenya has a land area of about 580,000 km² and a population of 46 million people across 47
counties (Figure 3.3). The capital, Nairobi, is the most populous city, home to about 3–4 million
people [81]. English and Swahili are the official languages.
The study population was recruited from Nairobi. Persons with mental disabilities and their family
members were randomly recruited through networks of persons with mental disabilities and relevant
Non-governmental organisations (NGOs). The main organisations include Users and Survivors of
Psychiatry (USP) Kenya and African Mental Health Foundation (AMHF), Kenya. The sampling of
study participants and stakeholders was based on relevance and experience of the study theme and
to engender participation and dialogue that may result in action and implementation of research
findings [78].
CHAPTER 3
34
Mental health care providers were purposively recruited from the Department of Psychiatry at
the University of Nairobi and via referrals from members of USP Kenya for the qualitative part
of the study. The mental health care providers involved in the survey arm of study 6 (Chapter 9)
were recruited online via networks of Nigerian doctors. Employers in the qualitative study were
identified through purposive sampling, referrals from USP members, and from the Federation of
Kenyan employers; while those in the quantitative study were sampled randomly. Disability NGOs
were identified through Light for the World (LFTW), Netherlands – a disability-specific NGO
with collaborators in Ethiopia, Kenya, Rwanda and Uganda. The disabled persons organisations
(DPOs) and TVET coordinators were purposively sampled based on their experience and
knowledge of LFTWs Employable programme for youths with disabilities. Further details
of the study participants are presented in Table 3.2 and the individual studies in Chapters 4 to
11. A brief summary of the specific methods used for each study is as follows:
In the first phase, the first study used the scoping-review method [82] and sought to identify the
barriers to and facilitators of employment for persons with psychiatric disabilities in Africa. The
initial scope was East Africa but in view of the dearth of studies, this was enlarged to Africa. The
dynamic adaptation of the bio-psychosocial model was used as an analytical framework [83].
The second study used the analytical-review method to explore legal and policy provisions for
reasonable accommodation in employment of persons with mental disability in East Africa. The
disability, labour and human rights laws of 18 East African countries (Figure 3.3) were obtained
from the database of WHO MiNDbank and the ILO and reviewed with reference to Article 27 of
Figure 3.3: Map of East Africa.
Source: Nyanchama V. List of East African countries and their capitals. 2018. https://tinyurl.com/y6hkv9e4
Research design
35
3
the CRPD [28]. The scoping review and policy review are in Chapters 4 and 5 respectively.
In the second phase, we adopted multiple study designs to address the main research question. In
the third study (Chapter 4) on lived experiences of persons with mental disability, a mixed-method
study design enabled the use of an emergent-research design to systematically integrate qualitative
and quantitative data to produce a synergetic and more robust effect [84]. The qualitative methods
used include semi-structured in-depth interviews and FGDs with persons with mental disabilities
[85]. The interviews adopted an open-ended semi-structured interview format [86] to explore
the lived experiences of persons with mental disabilities in Kenya in relation to employment.
Descriptive statistics was used to analyse the quantitative data while the qualitative data were
thematically analysed and presented as case studies. An iterative analytical process ensured
integration of the qualitative and quantitative data throughout the analysis [84].
Using a cross-sectional study design, the fourth study explored experienced and anticipated
discrimination and social functioning in persons with mental disabilities in Kenya in relation
to employment. The Social Functioning Questionnaire (SFQ) [87] was used to measure social
functioning, while experienced and anticipated discrimination were measured using Discrimination
and Stigma Scale (DISC-12) [88]. The SFQ and DISC are both validated scales useful for measuring
social functioning and discrimination respectively in persons with mental illness [87, 89]. Chi-
square, Fischer’s exact test and One Way Analysis Of Variance (ANOVA) were used to identify
group differences between the employed and unemployed persons with mental disabilities
depending on the distribution of the socio-demographic variables.
The fifth study adopted a mixed-methods study design to investigate employer perspectives on
opportunities to improve employment of persons with mental disabilities in Kenya. The qualitative
part of the study used open-ended semi-structured interviews while the quantitative part
used researcher-designed questionnaires. Qualitative data was analysed thematically. For the
quantitative data, bivariate and multivariate logistic regression models was used to explore the
association between employers and non-employers of persons with mental disabilities and their
characteristics (socio-demographics, knowledge, and perception). Integration of both qualitative
and quantitative data was ensured throughout the analysis.
In the sixth study, qualitative (interviews and FGDs) and quantitative (online survey) methods
were used to explore the perspectives of mental health care providers on pathways to improved
employment for persons with mental disability in Kenya and Nigeria respectively. Qualitative data
was thematically analysed while for quantitative data, descriptive statistics was used to describe
the perceived barriers to and facilitators of employment for persons with mental disabilities.
The seventh study used qualitative in-depth interviews to explore the barriers and pathways to
inclusion of persons with mental disabilities in TVET programmes in East Africa. The structure,
culture, and practice model [90] was used as a theoretical framework while data was analysed
using inductive content analysis.
CHAPTER 3
36
Stu
dy
Ph
ase
Stu
dy
titl
e M
eth
od
s St
akeh
old
er a
nd
nu
mb
er o
f pa
rtic
ipan
ts
Ch
apte
r
1
Bar
rier
s to
an
d f
acili
tato
rs o
f em
plo
ymen
t fo
r pe
op
le w
ith
psy
chia
tric
dis
abili
ties
in A
fric
a: a
sco
pin
g re
view
Lega
l an
d p
olic
y p
rovi
sion
s fo
r re
aso
nab
le a
cco
mm
od
atio
n in
emp
loym
ent
of p
erso
ns w
ith
men
tal d
isab
ility
in E
ast
Afr
ica:
A
revi
ew
Sco
pin
g re
view
Qu
anti
tati
ve (A
naly
tica
l rev
iew
)
No
t ap
plic
able
No
t ap
plic
able
4
5
2
Em
plo
yabi
lity
of p
erso
ns w
ith
men
tal d
isab
ility
: un
der
stan
din
g
lived
exp
erie
nce
s in
Ken
ya
Exp
erie
nce
d
and
A
nti
cipa
ted
D
iscr
imin
atio
n
and
So
cial
Fu
nct
ion
ing
in P
erso
ns
wit
h M
enta
l D
isab
iliti
es i
n K
enya
:
Impl
icat
ion
s fo
r E
mpl
oym
ent
Exp
ecta
tio
ns
man
agem
ent;
em
plo
yer
per
spec
tive
s o
n o
pp
ort
un
itie
s fo
r im
pro
ved
em
plo
ymen
t o
f p
erso
ns
wit
h
men
tal d
isab
iliti
es in
Ken
ya
Per
spec
tive
s o
f m
enta
l hea
lth
car
e p
rovi
der
s o
n p
ath
way
s to
impr
ove
d e
mp
loym
ent
for
per
son
s w
ith
men
tal
dis
abili
ty i
n tw
o lo
w-i
nco
me
cou
ntri
es
Ch
alle
nge
s of
incl
usi
on
: a q
ual
itat
ive
stu
dy
expl
orin
g b
arri
ers
and
pat
hw
ays
to in
clus
ion
of
per
son
s w
ith
men
tal d
isab
iliti
es
in
tech
nica
l an
d
voca
tion
al
edu
cati
on
and
tr
ain
ing
pro
gram
mes
in E
ast
Afr
ica
Mix
ed m
eth
od
(Su
rvey
,
inte
rvie
ws
and
FG
Ds)
Qu
anti
tati
ve (S
urv
ey)
Mix
ed m
eth
od
(Su
rvey
an
d
inte
rvie
ws)
Mix
ed m
eth
od
(Su
rvey
,
inte
rvie
ws
and
FG
Ds)
Qu
alit
ativ
e (I
nte
rvie
ws)
Per
sons
wit
h m
enta
l dis
abili
ties
N=
11
6
Per
sons
wit
h m
enta
l dis
abili
ties
N=
78
Em
plo
yers
N
=1
68
Men
tal h
ealt
h c
are
pro
vid
ers
N=
95
DP
O a
nd
TV
ET
co
ord
inat
ors
N=
10
6
7
8
9
10
3
Stak
eho
lder
s’ r
efle
ctio
n o
n t
he r
esu
lts
Qu
alit
ativ
e (r
ou
nd
tabl
e
dis
cuss
ion
s)
Per
sons
wit
h m
enta
l dis
abili
ties
,
fam
ily m
emb
ers,
em
plo
yers
, NG
Os,
men
tal h
ealt
h c
are
pro
vid
ers
and
p
olic
y-m
aker
s
N=
55
11
Tab
le 3
.2: O
verv
iew
of s
tud
y, m
eth
od
s an
d p
arti
cipa
nts
Research design
37
3
Finally, in the dissemination and dialogue meeting (third phase) we used a roundtable discussion and
reflection with relevant stakeholders to explore identified pathways for improved employability
for persons with mental disability in the previous phase of the study. The results from the first two
phases of the study were presented to the stakeholders followed by questions and answers and
dialogues between the stakeholders [78]. Finally, through roundtable discussion FGD, stakeholders
identified processes for achieving the identified pathways to improved employability for persons
with mental disability in Kenya. The results would be the start of the next research phase.
Research validity
We adopted several strategies in order to reduce bias and ensure the validity of the study findings
in all the phases of the study.
In the first phase of the study involving literature and analytical reviews, the reviews were
independently [82] undertaken by the researchers to ensure that identified studies and analysed
materials were not influenced by any one researcher; differences were resolved through discussions
until agreement was reached by all reviewers.
In the second and third phase of the study involving both qualitative and quantitative methods, we
used strategies based on the study type. For qualitative study, we avoided errors due to reactivity
and researcher bias [86]. Error of reactivity involves errors that occur because of the effect of the
researcher on the setting. In order to avoid this, we adopted open-ended and non-leading questions.
In addition, trained and experienced qualitative researchers were used throughout the study.
Researcher bias was reduced by the following methods: ensuring that data obtained was translated
verbatim, interviews conducted were back-translated, independent coding of qualitative data by
two researchers, validating of study findings by sharing with the study participants, involvement of
the study participants in the study and finally, we ensured that data saturation was achieved in the
qualitative studies. For the quantitative study, the questionnaires were either self-administered
or completed with the assistance of trained research assistants. The researcher-designed
questionnaire, Social Function Questionnaire [87] and DISC [91] were translated into Swahili and
back-translated. They were also pre-tested before data collection to ensure content validity.
Ethical considerations
The approval for the study design was granted by Amsterdam Public Health (WC2017-011) and
Maseno University Ethics Review Committee (MSU/DRPI/MUERC/00391/17). Approval was
also obtained from the Nairobi city council (REF:CHS/1/13/(6)-017). All study participants were
informed about the study and their written consent was obtained. All data obtained from the study
were anonymised in order to protect the identity of study participants. The data was stored in
a secure folder on the Faculty of Sciences (Vrije Universiteit) server and accessible only to the
principal researcher and supervisors. Audio files from the interviews were deleted after transcripts
were made. Data and information from the research were stored for a maximum period of 10
years (Institute for Health and Care Research (EMGO+) guidelines. All research data presented
subsequently as reports or scientific articles have no identifiable feature of study participants.
CHAPTER 3
38
3.4 Outline of the thesis
The first three chapters of the thesis describe the background of the study, the theoretical
underpinnings and research methods. Figure 3.2 describes the study outline.
Chapter 1 presents an overview of the challenges of employment for persons with mental
disabilities globally and then the context-specific factors in Africa and Kenya.
Chapter 2 reflects on the concept of disability according to different schools of thought and the
justification for inclusive employment for persons with mental disabilities.
Chapter 3 presents a summary of the research methods adopted in the study.
Chapters 4 & 5 present the findings of the literature (study 1) and policy review (study 2) on
evidence related to employment of persons with mental disabilities.
Chapters 6–10 explore the barriers to and facilitators of employment according to multi-stakeholder
perspectives. In Chapter 6, we focused on the lived experiences of persons with mental disabilities
in Kenya. In Chapter 7, we focused on the association between experienced and anticipated
discrimination and social function in employment of persons with mental disabilities in Kenya. In
Chapter 8, we investigated the perspectives of employers on opportunities for employment for
persons with mental disabilities in Kenya. In chapter 9, we explored the perspectives of mental
health care providers in Kenya and Nigeria on the pathways to employment for persons with
mental disabilities in both countries. In chapter 10, we explored the perspectives of coordinators
of DPOs in four East African counties on the challenges of inclusion in TVET programmes.
Finally, chapter 11 presents a concise account of the study dissemination event and the suggested
pathways to employment for person with mental disabilities according a multi-stakeholder
perspective (including family caregivers and policy-makers in addition to the previously listed
stakeholders) and reflection.
Research design
39
3
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Research design
45
3
Ebuenyi ID, Syurina EV, Bunders JF, Regeer BJ. Barriers to and facilitators of employment for
people with psychiatric disabilities in Africa: a scoping review. Global health action. 2018 Jan
1;11(1):1463658.
Published as
BARRIERS TO AND FACILITATORS
OF EMPLOYMENT FOR PEOPLE WITH
PSYCHIATRIC DISABILITIES IN AFRICA:
A SCOPING REVIEW
C H A P T E R 4
CHAPTER 4
48
4. BARRIERS TO AND FACILITATORS OF EMPLOYMENT FOR PEOPLE WITH PSYCHIATRIC DISABILITIES IN AFRICA: A SCOPING REVIEWAbstract
Background: Despite the importance of inclusive employment, described in Goal 8 of the
Sustainable Development Goals (SDGs), employment of persons with psychiatric disabilities in
Africa is lower than among the general population.
Objective: The aim of this scoping review is to explore evidence related to the barriers to and
facilitators of employment of persons with psychiatric disabilities in Africa.
Methods: A literature search was conducted using six relevant electronic databases of articles
published between 1990 and 2017.
Results: Eight studies were identified and analysed regarding barriers and facilitators of
employment of persons with psychiatric disabilities. The dynamic adaptation of the bio-psycho-
social model was used as an analytical framework. Identified barriers include ill health, (anticipated)
psychiatric illness, social stigma and discrimination, negative attitudes among employers and the
lack of social support and government welfare. Facilitators of employment include stability of
mental illness, heightened self-esteem, a personal decision to work despite stigma, competitive
and supported employment, reduction in social barriers/stigma and workplace accommodations.
Conclusion: Employment of persons with psychiatric disabilities is essential, yet there is dearth of
scientific evidence to identify contextual models that might be useful in African countries and other
low-and middle countries (LMICs). This gap in information would benefit from further research to
improve the employment rates of persons with psychiatric disabilities in Africa.
Keywords: psychiatric disability, social stigma, personal decision, supported employment, low- and
middle-income countries
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
49
4
4.1 Background
Worldwide, employment rates among people with psychiatric disability are significantly lower than
those of general population and even of individuals with other types of disabilities [1, 2]. According
to the Organization for Economic Co-operation and Development (OECD), mental health problems
constitute 30-45% of all disability claims [3]. Some studies report that the employment rate among
this group is 40% lower, while others state that only 25% of those with a mental disability are
employed [3]. Studies suggest that this employment gap is especially evident in low- and middle-
income countries (LMICs) because of the underlying socioeconomic and political reasons affecting
the employment market and social welfare policies [1, 2].
Such an employment gap between people with a mental disability and the general population
can only partially be explained by the disorder; true employment rates may be masked by stigma
and discrimination that are closely associated with mental health issues [4]. These often militate
against programmes that aim to improve the employability of persons with a disability [2, 5].
Such misconceptions have huge ethical implications and socioeconomic effects on the lives of
those affected [2], as it is known that increased economic participation is not only financially
advantageous but also has a positive impact on the course of disease [6] and prevents recurrence
[7].
When discussing mental health-related disabilities, it is important to highlight the lack of consensus
on what constitutes mental disability. Severe mental illnesses such as schizophrenia, bipolar
disorder and schizoaffective disorders are major causes of mental disability [8]. Also, globally,
depression is one of the leading causes of disability [9], but in some African countries it is hard
if not impossible to get a disability status approved for Common Mental Disorders (CMD) [10].
Taking this contextual specificity in mind, this review focuses on severe mental health disorders.
In order to be able to influence the employment rates of people with mental health disabilities,
it is important to have an overview of existing barriers and known facilitators. Among the
known barriers are: illness-specific factors, discriminatory attitudes among employers, lack of
education and skills, and the failure to implement government provisions and recommendations
for employment of persons with disabilities [11]. To overcome such barriers, studies recommend
models such as supported employment (SE) for the employment of persons with mental disability
[12]. In some settings, microfinance and cash transfers have been recommended to boost self-
employment as an alternative to SE programmes [2, 13], especially in LMICs.
Although there are evidence-based studies on barriers to and facilitators of employment of persons
with a mental disability in HICs [5, 12, 14], few studies have systematically explored the subject in
African countries [15]. This, combined with calls in the United Nations Convention on the Rights
of Persons with Disabilities (UNCRPD) [16] and the Sustainable Development Goals (SDGs)
[17], have advocated concerted action to protect the rights of persons with disabilities and their
empowerment through inclusion in socioeconomic programmes. In this vein, this study adopts the
exploratory approach of scoping reviews [18] and evaluates qualitative and quantitative studies on
CHAPTER 4
50
psychiatric disability in Africa in order to identify the barriers to and facilitators of employability
for individuals with a psychiatric disability as well as existing employment models for persons
with psychiatric disabilities in the region. In this study, psychiatric and mental disability are used
interchangeably and refer to individuals with a form of mental illness that affects their social and
occupational functioning [19].
4.2 Theoretical approach
The issue of employment of individuals with a psychiatric disability can be influenced by
a wide range of factors, of which some are linked to the individual in question, namely sex
[20], age, specific diagnosis, duration and severity of the condition [21, 22]; while others
are more linked to the surrounding environment, i.e. family structure and support [23],
prevalence of stigmatizing beliefs in the community and existing policy documents [24]. In
order to discuss this broad spectrum in a systematic way, the expansion of the bio-psycho-
social model by [25] was adopted. This model builds on conventional bio-psycho-social
approaches [26] by introducing a dynamic systems perspective and applying Bronfenbrenner’s
theories of development in order to underline the social influences.
Beyond the original three elements – biological (physical elements and body characteristics),
psychological (cognitive, emotional, motivational, attitudinal, and behavioural system) and
interpersonal (effects of actual or perceived social contacts on micro, meso and exo-levels) – the
model adds the contextual aspects (broad-range culture, norms, policies, and values) and specifically
focuses on the way the four groups influence each other and the person’s health. Moreover, it takes
a developmental perspective on the elements, taking into account that they change over time, and
hence are referred to as ‘dynamics’.
4.3 Methods
Search Strategy
The review was conducted using the Joanna Briggs Institute (JBI) Methodology for Scoping
Reviews [18]. The objectives, inclusion criteria and methods were specified in advance in the study
protocol.
Data collection
A systematic search was undertaken across six relevant databases (CINAHL, EMBASE, PsycINFO,
PUBMED, SCOPUS and Web of Science) on 9 March 2017. An updated search was conducted in
September 2017. The search terms were based on the synonyms of: mental/psychiatric disabilities;
employment; and a list of all African countries. Boolean operators AND; OR and NOT were used to
construct the syntax (see Appendix 4.1). All relevant articles relating to the employment of people
with a psychiatric disability in Africa from 1990 to September 2017 were captured. Identified
articles were exported to Endnote.
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
51
4
The initial search yielded 3771 papers and this was reduced to 2890 after eliminating 911
duplicates. Title and abstract screening was conducted using the predefined eligibility criteria
(Table 4.1) by IDE and EVS and 11 articles were selected for full-text screening, following which
eight were selected for the review. The process of study selection, performed according to the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [27], can be
found in Figure 4.1.
Inclusion Exclusion
Study Design Quantitative and qualitative studies including
RCT, non-randomized controlled trials, cross-sectional studies, cohort studies and case-
control.
Case reports/series, editorials,
opinion pieces, interviews, systematic reviews, or books.
Date of Publication None None
Language All Languages None
Study Population All adults 18 years or above diagnosed with mental/psychiatric disability
Adolescents/children under 18 years, diagnosis of Common Mental
Disorder only
Study Outcome Barriers (illness, stigma/discrimination, lack
of skills/education, absence of legislation and
government support) and opportunities (social support, education, information,
government support and policies,
employment/rehabilitation models for
employment) for study subjects
Other outcomes unrelated to
outcome of interest
Table 4.1: Eligibility Criteria
Analysis
To synthesize the collected evidence, an extraction table was created. The following items
were included: author, year of publication, study setting (including country), study design,
study population, sample description and setting, main findings and limitations. The extraction
was conducted by IDE and reviewed together with EVS BJR and JFGB. A summary of the data
extraction is presented in Table 4.2.
Once data extraction had been completed, a narrative synthesis [28] was undertaken, based on
the study objective and the exploratory nature of the study. All the findings of each paper were
analyzed and coded according to the divisions of the bio-psycho-social model; coding findings from
each category were synthesized, analyzed and presented in a narrative way.
4.4 Results
Eight studies were included in the analysis. We observed a dearth of studies on the barriers to and
facilitators of employments of persons with psychiatric disabilities in African countries. The identified
studies had a varied, yet relatively limited, geographical range: three each were from Nigeria [29-
31] and South Africa [32-34] and the remaining two were from Malawi [35] and Ghana [36].
CHAPTER 4
52
Methodologically, six of the studies were quantitative: five had a cross-sectional design [29-31,
35, 36], one was a longitudinal study [34], and two used a qualitative research approach [32, 33].
Five of the studies focused on experiences of individuals diagnosed with psychiatric disorders [30,
32-34, 36], while the remaining three investigated the perspectives of human resource personnel
[29], employers [35] and senior civil servants [31]. Two of the studies of persons with psychiatric
disabilities were in settings offering vocational rehabilitation services [30, 36], one was in a clinical
setting offering SE [34] while the other two explored work-participation perceptions of individuals
with psychiatric illness in society in general [32, 33].
Identified barriers and facilitators will be discussed separately in accordance with the dynamic
representation of bio-psycho-social model by Lehman et.al. [25]. Our choice to contextualize
the results using the bio-psychosocial model was to ensure a systematic presentation of all the
different factors at play. Although, it would have been useful to present the results according to
the different actors relevant to employability, the available data made this impossible. For instance,
the studies on employers or individuals involved in employment decisions focused on the attitude
of employers and not their perceptions on barriers and on how to improve employment for person
with mental disabilities.
Figure 4.1: PRISMA Flowchart of Study Selection Process
Included Screening
Eligibility Identification
3771 articles identified from 6 electronic databases
CINAHL (155); EMBASE (1023); PsycINFO (735); PUBMED(602); SCOPUS (440) Web of
Science (456)
2890 articles screened (title and abstract) after removal of duplicates
11 studies assessed (full text) for eligibility
8 studies included in the review
911 duplicates removed
2879 articles excluded using the eligibility criteria
3 studies excluded using the eligibility criteria
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
53
4
Tab
le 4
.2: S
tud
y C
har
acte
rist
ics
and
Fin
din
gs
Au
tho
r &
Yea
r C
ou
ntr
y St
ud
y D
esig
n/
Met
ho
ds
Stu
dy
Po
pu
lati
on
/S
etti
ng
Stu
dy
Aim
M
ain
fin
din
gs
Lim
itat
ion
Oye
feso
, 19
94
(30
)
Nig
eria
C
ross
-sec
tio
nal
surv
ey u
sing
sel
f-ad
min
iste
red
qu
esti
on
nai
res
(att
itu
de
tow
ard
s
the
wo
rk
beh
avio
ur
of e
x-
men
tal p
atie
nts
sc
ale
(AT
WB
S)
48
0 s
enio
r fe
der
al
civi
l ser
van
ts fr
om
1
7 fe
der
al
min
istr
ies
in
Nig
eria
To
exa
min
e th
e
atti
tud
e o
f sen
ior
civi
l ser
van
ts
tow
ard
s th
e w
ork
be
hav
iour
of e
x-
men
tal p
atie
nts
77
% o
f re
spo
nd
ents
had
nev
er w
ork
ed w
ith
ex-
men
tal
pat
ien
ts
and
7
2%
in
dic
ated
th
eir
unw
illin
gnes
s to
wor
k w
ith
the
m.
67
% s
aid
the
go
vern
men
t w
as n
ot
doi
ng
eno
ugh
to
pro
tect
th
e ri
ghts
of e
x-m
enta
l pat
ient
s w
hile
they
are
ho
spit
aliz
ed.
On
ly 1
2%
are
aw
are
of
wel
fare
po
licie
s fo
r ex
-
men
tal
pat
ien
ts
in
the
wo
rkpl
ace
and
8
8%
agre
ed t
hat
ther
e is
nee
d fo
r a
wel
fare
po
licy
for
ex-m
enta
l pat
ien
ts in
th
e w
ork
pla
ce.
Th
e re
spo
nse
ra
te
of
sam
ple
of
popu
lati
on w
as
76
%.
Her
zig
and
T
ho
le 1
99
8
(34
)
Mal
awi
Cro
ss-s
ecti
on
al
surv
ey
58
em
plo
yers
fro
m
Mzu
zu, M
alaw
i
To
exp
lore
ho
w
the
atti
tud
e o
f lo
cal e
mpl
oye
rs
affe
cts
emp
loym
ent
of
peo
ple
wit
h
men
tal i
llnes
s
52
% o
f em
plo
yers
sta
ted
thei
r w
illin
gnes
s to
emp
loy
psy
chia
tric
p
atie
nts
if
they
w
ere
curr
entl
y w
ell a
nd
rec
ove
red
; an
d w
ere
will
ing
to
pro
vid
e w
ork
plac
e ac
com
mo
dati
ons
for
them
.
In
a co
mpa
riso
n
bet
wee
n
asth
ma
and
sc
hizo
ph
reni
a, 2
8%
(1
3)
of
emp
loye
rs s
aid
th
ey
wo
uld
hir
e n
eith
er; 1
1%
(5) p
refe
rred
to
em
plo
y th
e p
atie
nt
wit
h a
sthm
a w
hile
9%
(4) (
emp
loye
rs
need
ing
lab
oure
rs)
wo
uld
ra
ther
h
ire
the
psy
chia
tric
pat
ien
t.
All
bu
t on
e o
f th
e em
plo
yers
sta
ted
ther
e w
as n
o
ince
nti
ve fo
r th
em to
hir
e p
erso
ns
wit
h d
isab
ility
or il
lnes
s.
Th
e re
spo
nse
rat
e o
f
sam
ple
of p
opul
atio
n w
as
76
%. T
he a
uth
ors
no
ted
that
th
e em
plo
yers
may
h
ave
off
ered
so
cial
ly
des
irab
le a
nsw
ers.
Eat
on
, 20
08
(2
9)
Nig
eria
C
ross
-sec
tio
nal
surv
ey u
sing
stru
ctu
red
q
ues
tio
nn
aire
.
41
ex-
resi
den
ts
(Sev
ere
men
tal
illn
ess)
of A
mau
do
Itu
mb
auzo
(Sou
th
Eas
t N
iger
ia)
voca
tio
nal
To
exa
min
e w
ork
enga
gem
ent
of e
x-
resi
den
ts
disc
har
ged
fro
m
the
reh
abili
tati
on
faci
lity
18
(36
%) w
ere
enga
ged
in t
he
wo
rk a
ctiv
ity
and
out
of t
hes
e n
um
ber
10
wer
e fa
rmin
g, 6
wer
e
trad
er a
nd
the
rem
ain
ing
2 w
ere
invo
lved
in
hair
dres
sin
g an
d m
anu
al la
bo
r.
Inte
rvie
wer
ad
min
iste
red
qu
esti
on
nai
res
may
lead
to
soci
ally
des
irab
le a
nsw
ers.
CHAPTER 4
54
reh
abili
tati
on
p
rogr
amm
e.
82
% o
f th
ose
wo
rkin
g sa
w t
he
com
mun
ity
psy
chia
tric
nu
rse
in t
he
last
mon
th.
Men
tal
illn
ess
(27
.5%
), p
hysi
cal
illn
ess
(12
.8%
),
soci
al f
acto
rs (
e.g.
fam
ily r
ejec
tio
n)
(17
.5%
) an
d
lack
o
f to
ols
/eq
uip
men
t ar
e th
e re
po
rted
b
arri
ers
for
no
t w
ork
ing.
Am
ong
tho
se n
ot
wo
rkin
g, 5
2%
nev
er r
esu
med
wo
rk a
fter
dis
char
ge.
Bo
yce
et a
l.,
20
09
(35
) G
han
a C
ross
-sec
tio
nal
Surv
ey
40
0
men
tally
ill
peo
ple
(c
linic
al
dia
gno
sis)
in B
asic
s N
eed
s (G
han
a)
dev
elo
pmen
t
pro
gram
me
To
exa
min
e th
e
rela
tio
nsh
ip
bet
wee
n
soci
oec
on
om
ic
indi
cato
rs (e
.g.
asse
t o
wn
ersh
ip,
job
ret
enti
on
aft
er
men
tal i
llnes
s) a
nd
impr
ove
men
t/st
ab
ility
of m
enta
l
illn
ess.
Stab
ility
o
f ill
nes
s an
d
hig
h
self
-est
eem
ar
e
asso
ciat
ed w
ith
em
plo
ymen
t an
d jo
b r
eten
tion
.
On
set o
f men
tal i
llnes
s is
ass
oci
ated
wit
h jo
b lo
ss
(OR
-4.8
6;1
.51
-15
.63
)
(NB
un
stab
le-l
ast
exp
erie
nce
d il
lnes
s≤6
mo
nth
s
ago;
sta
ble
-≥7
mo
nth
s ag
o)
Illn
ess
stab
ility
is
sub
ject
ive
and
may
be
affe
cted
by
reca
ll b
ias.
Inte
rvie
wer
ad
min
iste
red
q
ues
tio
nn
aire
s m
ay le
ad t
o
soci
ally
des
irab
le a
nsw
ers.
Nie
kerk
, 20
09
(3
1)
Sou
th
Afr
ica
Qu
alit
ativ
e In
terv
iew
s us
ing
inte
rpre
tive
b
iogr
aph
y
17
per
son
s w
ith
p
sych
iatr
ic
dis
abili
ty (a
xis
1 o
f D
SM IV
) fro
m t
he
Wes
tern
Cap
e,
Sou
th A
fric
a
To
exa
min
e th
e fa
cto
rs t
hat
aff
ect
the
wo
rk li
ves
of
peo
ple
wit
h
psyc
hia
tric
d
isab
ility
Stig
ma
and
dis
crim
inat
ion
aff
ecte
d w
ork
o
ppo
rtu
nit
ies
of p
erso
ns
wit
h p
sych
iatr
ic
dis
abili
ty.
Per
son
s w
ith
psy
chia
tric
dis
abili
ties
in
tern
aliz
e so
ciet
al
ster
eoty
pes
th
at
they
ca
nn
ot
wo
rk,
wh
ich
red
uce
s th
eir
wor
k ab
ility
.
Flu
ctu
atio
ns
in h
ealt
h (p
sych
iatr
ic il
lnes
s) le
d t
o
job
loss
.
Res
olv
ing
the
iden
tity
cri
sis
(wo
rk a
bili
ty),
flex
ibili
ty/j
ob
ch
ange
, sel
f-es
teem
an
d a
per
son
al d
ecis
ion
to w
ork
en
han
ces
wo
rk
dec
isio
n a
nd
em
plo
ymen
t.
Pu
rpo
sive
sam
plin
g w
as
use
d.
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
55
4
Co
mp
etit
ive
emp
loym
ent
is
very
h
elp
ful
for
reso
lvin
g id
enti
ty c
risi
s.
Ati
lola
et
al.,
20
14
(28
)
Nig
eria
C
ross
-sec
tio
nal
surv
ey u
sing
sel
f-ad
min
iste
red
qu
esti
on
nai
res
and
the
mo
difi
ed
vers
ion
of L
ink’
s D
iscr
imin
atio
n
dev
alua
tio
n (L
DD
) sc
ale
90
Hu
man
reso
urce
(HR
) p
erso
nn
el a
nd
emp
loye
rs fr
om
co
mp
anie
s in
Lago
s, N
iger
ia.
To
exa
min
e th
e
fam
iliar
ity
and
at
titu
de
of H
um
an
reso
urc
e pe
rso
nnel
to
men
tal h
ealt
h
issu
es in
wo
rkp
lace
.
53
.3%
of
resp
ond
ents
hav
e n
egat
ive
atti
tud
e
tow
ard
s m
enta
l h
ealt
h is
sues
in
th
e w
ork
plac
e an
d 7
2.2
% w
ould
rat
her
em
plo
y so
meo
ne
wit
h a
phy
sica
l di
sabi
lity
than
a m
enta
l ill
nes
s. 7
3.3
%
wo
uld
no
t w
ant
to s
har
e an
off
ice
wit
h s
om
eon
e
wit
h m
enta
l illn
ess.
Wor
kpla
ce
safe
ty
(82
.5%
) w
as
the
maj
or
rest
rain
t in
re
com
men
din
g fo
r em
ploy
men
t so
meo
ne
wit
h m
enta
l ill
nes
s fo
llow
ed b
y w
ork
pro
du
ctiv
ity
(68
.6%
), re
acti
on
of
oth
er
emp
loye
es
(56
.85
%)
and
fi
nan
cial
b
urd
en
of
pos
sib
le c
are
(36
.8%
)
Th
e re
spo
nse
rat
e o
f
com
pan
ies
sam
ple
d w
as
18
.4%
Nie
kerk
, et
al.,
20
15
(33
) So
uth
A
fric
a Lo
ngi
tudi
nal
d
escr
ipti
ve s
tud
y 1
0 p
erso
ns
wit
h p
sych
iatr
ic
dis
abili
ty u
tiliz
ing
sup
port
ed
emp
loym
ent
serv
ices
fro
m a
psy
chia
tric
h
osp
ital
in C
ape
To
wn,
Sou
th
Afr
ica.
To
des
crib
e th
e pa
rts
of S
E
serv
ices
use
d b
y pe
rso
ns w
ith
men
tal d
isab
ility
SE i
s a
use
ful
opt
ion
fo
r re
turn
to
wo
rk f
or
per
son
wit
h p
sych
iatr
ic d
isab
iliti
es.
Per
man
ent
job
s o
bta
ined
b
y p
erso
ns
wit
h
psy
chia
tric
di
sabi
litie
s in
clu
de
vege
tabl
e fa
rmin
g,
pap
er
mak
ing,
fo
od
p
rod
uct
ion
an
d
boo
k p
acka
gin
g.
Pu
rpo
sive
sam
plin
g w
as
use
d.
Nie
kerk
, 20
16
(3
2)
Sou
th
Afr
ica
Qu
alit
ativ
e
Inte
rvie
ws
usin
g in
terp
reti
ve
bio
grap
hy.
17
per
son
s w
ith
psy
chia
tric
d
isab
ility
(axi
s 1
of
DSM
IV) f
rom
th
e
Wes
tern
Cap
e,
Sou
th A
fric
a.
To
exa
min
e th
e
con
cep
t o
f wo
rk
iden
tity
in t
he
wo
rkp
lace
by
pers
ons
wit
h
psyc
hiat
ric
disa
bilit
y
Co
min
g to
term
s w
ith
men
tal i
llnes
s an
d d
ecis
ion
to f
igh
t th
e so
cial
fact
ors
enh
ance
s em
plo
ymen
t op
port
uni
ties
.
Flex
ibili
ty in
sel
f-id
enti
ty e
nhan
ced
wo
rker
rol
e.
Psy
chia
tric
illn
ess
led
to
dis
rupt
ion
of
wor
k an
d
fear
/an
tici
pat
ion
o
f fu
ture
re
lap
se
affe
cted
em
plo
ymen
t.
Pu
rpo
sive
sam
plin
g w
as
use
d.
CHAPTER 4
56
Barriers of Employment for People with Psychiatric Disability
Our analysis identified five major clusters of barriers to employment: presence and severity of
illness, underlying psychological load (including fear of relapse), social stigma, discrimination and
negative attitudes by others, lack of skills/education and absence of policy support.
Biological factors
One of the most frequently named barriers to successful employment for people with mental health
disabilities was ill health. Some papers talked about the effects of the more physical symptoms [30].
From the sample of 41 ex-residents of a vocational rehabilitation programme, 12.8% named the
presence of co-morbid physical illness as a barrier to obtaining work. Most of the other papers
identified psychiatric illness itself as a limitation to employment and participation in employment
or job-related activities [30, 32, 33, 36]. Mental illness was the highest (27.5%) self-reported
barrier to the inability to work in a study to explore the work engagement of former residents of a
psychiatric rehabilitation centre [30]. In addition, the fluctuation of psychiatric illness was strongly
associated with job loss [32, 33, 36] and affected the desire to seek employment in the studies of
persons with psychiatric illness.
Psychological factors
Niekerk and colleagues showed that apart from the presence of the mental health disorder itself,
anticipation and fear of a relapse in symptoms was associated with a reduced desire to seek or
retain employment in persons with psychiatric disorders. [33].
Interpersonal/social factors
The interpersonal factors that influence the ability and motivation to find employment can broadly
be described as prevalence of negative and stigmatizing attitudes and beliefs. Social stigma and
discrimination were reported as a barrier to employment for people with psychiatric disabilities in
six of the eight studies included in the study [29-33, 35]. Such beliefs can be held by different actors
in the individual’s environment, including family members and employers or their representatives
(e.g. human resource personnel and senior civil servants).
In a cross-sectional survey in Nigeria, Eaton [30] reported that family rejection (17.5%) of persons
with severe mental illness was the second highest self-reported barrier to employment after
psychiatric illness in former residents of a psychiatric rehabilitation centre. Further, self-stigma
plays a role – it was identified that a prevalent social stereotype in South Africa is that people with
psychiatric disabilities cannot work and affected individuals internalize these perceptions, which
also reduces their ability to work or motivation to secure employment [32].
Several of the identified papers discussed the employers’ and their representatives’ beliefs and
attitudes as employment barriers. A survey of human resource personnel in Nigeria revealed that
72.2% of respondents would rather work with people with physical than mental illness and 73.3%
would not want to share an office with someone with a mental illness [29]. Workplace safety was
the major reason the human resource personnel would not recommend someone with mental
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
57
4
illness for employment, while the perception that people with mental illness would be a burden
was the least concern [29].
Negative attitudes among employers observed in a survey of senior federal civil servants in
Nigeria found that 72% of the respondents indicated their unwillingness to work with people with
mental illness and 77% had never done so [31]. In the same study, 67% of respondents agreed
that government welfare for the care of persons with mental illness was sub-optimal. In a cross-
sectional survey in Malawi, Herzig and Thole [35] reported that although 52% of employers
indicated their willingness to hire persons with a psychiatric illness, they would only do so if they
were ‘currently stable. In the same study, employers were more likely to hire someone with asthma
(11%) than schizophrenia (9%) while 28% declared they would hire neither. In two qualitative
studies in South Africa, both experienced stigma and anticipated discrimination were noted
barriers to the employment of people with psychiatric disabilities [32, 33].
Contextual factors
Among the identified contextual factors were lack of tools for work and relative absence of
government policy support. The study by Eaton [30] showed that lack of farming tools or
equipment was the highest (32.5%) self-reported barrier to the ability to work among people with
severe mental illness. This was often because of lack of money to buy or replace spoilt tools or the
inability of the vocational training centre to replace the tools. Refusal to work (2.5%) and forgotten
skills (5%) were other self-reported barriers in persons with mental illness [30].
Linked to that, several studies discussed a more structural, higher-level barrier: lack of
institutionalized policy protection for people with mental illnesses. In the study by Oyefeso et al.
[31] it was reported that 67% of the participating senior civil servants think that the government
was not doing enough to protect the mental health patients. Moreover, 88% of respondents agreed
that there was a need for a welfare policy for people who had been mental health patients. In the
study by Herzig and Thole [35], while 52% from the sample of 58 employers were willing to employ
a person with mental health disability, all but one reported the absence of policy or other incentives
for them to do so.
Facilitators of Employment for People with Psychiatric Disability
We found five clusters of facilitators of employment for person with psychiatric disabilities, namely
stability or reduced severity of mental illness, resolution of psychological conflicts, workplace
accommodations, reduction in social barriers/stigma and governmental support.
Biological factors
Stability of mental illness and utilization of mental health services were reported as facilitators of
employment and job retention [30, 36]. Job retention was two (OR=2.19,95% CI=1.27-3.78) and
five times (OR=4.86,95% CI=1.51-15.63) more likely in those with stable and improved mental
illness respectively [36]. The association between working and stable mental health care was
noted in a cohort of individuals with severe mental illness, where 82% of those who were working
CHAPTER 4
58
sought care from the community psychiatric nurse (CPN) in the last month [30].
Psychological factors
Resolution of a personal psychological conflict, heightened self-esteem and a personal decision
by an individual with a psychiatric disability to work in spite of stigma are reported as major
determinants of employment and work [32-34]. In two separate qualitative studies with individuals
with psychiatric disabilities, Niekerk [32, 33] reported that the personal decision to work [32] and
coming to terms with mental illness and consciously deciding to overcome the social barriers [33]
enhances employment opportunities. Self-esteem and confidence in one’s work ability increased
the likelihood of employment and job retention [32, 33]. These observations by Niekerk [33] are
captured in the statement:
A further trend was that participants who were more at ease with the effects of psychiatric
impairment on their identity and functioning seemed better able to maintain their roles…..
participants who resumed work despite the occurrence/continuation of mild symptoms were
more successful in maintaining such participation. [33]
Interpersonal
Among the interpersonal factors facilitating employment are the ones linked to the direct working
environment of individuals with mental disabilities. In her study, Niekerk [32] identified that
competitive employment was helpful for resolving an identity crisis of individuals with a disability
and thus facilitate their employment. In a later study by the same author, it was shown that SE
and provision of additional assistance during work is useful for the return to work for people with
mental disabilities [34].
Contextual factors
Reduction in social stigma and improved social welfare were also reported facilitators of
employment for people with psychiatric disabilities [29, 31-34]. The survey of senior federal
civil servants in Nigeria reported that 88% of respondents agreed that welfare policy in the
workplace is essential for the employment of a person with mental illness. In addition, workplace
accommodations were identified as relevant for improved work opportunities for people with
psychiatric disabilities [31].
Despite the fact that in this study we identified certain biological, psychological, interpersonal
and contextual factors that are shown to influence the employment of our study group, it is
also important to bear in mind the interconnectedness and mutual influence of these factors as
presented by Lehman et al. [25]. All the biological, psychological and interpersonal challenges that
persons with psychiatric disabilities experience are interrelated and also influenced by contextual
factors that operate in their environment. These factors (inter)act to determine the specific barriers
and facilitators to employability the individual experiences (Figure 4.2). They are in constant flux
and the dynamic interaction between them determines whether an individual secures or retains
employment amidst the challenges of physical and psychiatric illness, social support/network
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
59
4
and the contextual factors in the local environment. For instance, an individual with co-morbid
psychiatric illness and physical health challenges, who is also exposed to work-related stigma, may
be able to stay in employment depending on the availability of a positive or negative social network.
Another example could be an individual with a psychiatric illness who lives in a community where
s/he is likely to be stigmatized, but who is protected by national law, has different employment
possibilities than a person without such protection.
Other facilitators of employability for people with Psychiatric disabilities
Employment models such as sheltered or supported employment are used in HICs to facilitate the
employment of persons with a disability [37-39]. Where they exist and are taken up, they increase
the employment opportunities for persons with a disability [13, 38]. In this study, we observed
three models of employment for persons with psychiatric disabilities. First, self-employment
through farming and other self-help schemes were identified as major means of employment. Of
18 individuals involved in work in a vocational rehabilitation programme for people with severe
mental illness, ten were involved in farming [30].
Second, cooperative income-generation groups of persons with psychiatric disabilities was
reported as a useful model of employment and a pathway towards competitive employment and
resolution of work identity crisis [32]. Cooperative income-generation groups were useful because
Figure 4.2: Adapted from Lehman et al. [25] showing the dynamic interaction of bio-psycho-social factors in the
employability of persons with psychiatric disabilities
CHAPTER 4
60
the individuals were able to work among other disabled persons and so felt accepted [32].
Third, SE services which assist persons with psychiatric disabilities to engage in competitive
employment were identified as a useful option for the return to work of people with psychiatric
disabilities in resource-poor settings [34]. Where they exist, SE may serve to facilitate the
employability of persons with psychiatric disabilities.
4.5 Discussion
Our study observed a striking lack of evidence regarding the employment of people with psychiatric
disability throughout Africa. Despite using broad selection criteria, we were able to identify just
eight papers discussing the issue. There may be several explanations. In African countries, there
is associated stigma and lack of interest in mental illness; a situation that is worsened by lack of
human resources for mental health care [4, 40]. The stigma may be related to the attribution of the
etiology of mental illness to supernatural causes [41]. This understanding informed the proposal
by Gureje and colleagues for a collaboration between traditional and complementary systems of
medicine (TCM) and conventional biomedicine (CB) in the care of persons with mental illness [42].
In addition, there is a lack of interest in mental health and of the political will to develop policies to
advance mental health care at the same pace as addressing other health challenges in Africa [43].
In this article, we presented an overview of the barriers to and facilitators of employment for
people with psychiatric disabilities in Africa. The analysis was performed using the expansion of
the bio-psycho-social model [25]. In the analysis, a certain imbalance of attention was noted, as
there seems to be more research on barriers than on facilitators. This can, however, be explained
by the importance of describing the field, before facilitating actions can be made. When analyzing
the barriers to and facilitators for employment, it became visible that most can be seen as two
sides of the same coin. Depending on the situation and approach they can either hinder work
participation or facilitate employment.
The biological factors influencing work participation are linked to the physical or mental health
of the individual in question. Several studies have noted that fluctuation in mental illness led to
disruption of work and inability to continue in a job [30, 32, 33, 36]. On the other hand, others have
shown that stability in the course of mental illness can help individuals to find and maintain work
[36]. Previous studies on severe mental illness found that untreated or current mental illness is
associated with impaired social and occupational functioning [44]. One of the factors contributing
to the stability of mental health issues is timely and adequate access to care: Eaton [30] also noted
that among persons with mental illness who were in work, 82% had seen the community psychiatric
nurse in the last month. Broader research shows that availability of treatment and its uptake are
known facilitators of wellbeing and employment for people with psychiatric disabilities [45].
The biological barriers to employment seem to be closely linked to the psychological ones. It was
shown that the anticipation of psychiatric illness affects work ability, because the individual feared
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
61
4
that the illness may recur and lead to interrupted employment [32]. These findings are not unique
to African countries, and have been observed in varied countries around the world [5, 8, 46]. Other
studies also found that taking a personal decision to work and being able to establish a personal
means of coping with the hardships of the disease and the associated stigma can have positive
impact on work ability and retention [32-34]. This is useful because it highlights the importance
of choice and yearning for survival in the face of overwhelming challenges. Every person’s ability
to cope may differ, but its use in cognitive behavioural therapy (CBT) may be essential for health
professionals who work with people with a psychiatric illness.
In order to foster these coping strategies, it is also important to address stigma and negative
beliefs about the psychiatric disabilities, which several studies find constitutes a considerable
interpersonal barrier to employment of our target group [32]. Pervasive and negative attitudes
to the work ability of individuals with psychiatric illness were recorded in three studies conducted
with human resource personnel [29], employers [35] and senior federal civil servants [31].
These findings are supported by several studies in HICs that have demonstrated that stigma and
discrimination in both society and the workplace adversely affect the employment of persons with
psychiatric illness [2, 5, 12, 47]. It was also frequently noted that the reduction of social barriers
and stigma is useful in the participation in work of people with psychiatric disabilities [30, 32, 33].
Krupa and colleagues recommend intervention strategies to reduce the harmful of effects of
stigma at work [48]. These interventions would involve workplace accommodations and changes
in pervasive attitudes and assumptions which were recorded as barriers to employment for people
with mental disabilities in this study [29-33].
The identified contextual factors influencing the employment of people with psychiatric disabilities
in Africa were connected both to more practical aspects (absence of necessary tools), and also
highlighted a more structural problem – the absence of government policy support.
Limited access to the necessary tools and equipment for work was described as an underlying
factor that could explain reduced work participation [30]. This finding highlights a close relationship
between poverty and mental illness and the twin factors of social causation and social drift, closely
associated with psychiatric disability [49]. This is especially instructive because in LMICS self-
employment through farming and personal business provide employment for the majority and
people with psychiatric disabilities who face social and institutional workplace exclusion [2]. It is
also pertinent to state that the lack of finance may not be due to mental illness and there was no
comparison group in the study to demonstrate an association between lack of farming tools and
mental illness.
Last, but not the least, the need for government support for the issue of employment of people
with psychiatric disabilities was highlighted in several papers [31, 35]. There seems to be a notable
lack of policy protection for the target group. At present, this notion is supported by the UNCRPD
[16] and the SDGs [17]. Governments everywhere have a duty towards persons with disabilities
through legislation and provision of basic facilities, such as health care [4, 16]. In addition, legislation
CHAPTER 4
62
against discrimination and job quotas for people with psychiatric disabilities are suggested means
by which governments can assist persons with psychiatric disabilities [2].
However, when reviewing the results of this study one should be aware that the barriers and
facilitators identified do not exist in isolation, but rather mutually influence each other. This
presents both a challenge and an opportunity for potential interventions in the field. And we
advocate more research about this interconnectedness.
This study also recorded three models or sources of employment for people with psychiatric
disabilities, namely self-employment [30], cooperative groups [32] and supported employment
[34]. Self-employment through farming was noted as a major form of employment for individuals
with psychiatric illness [30]. This is supported by the literature and is particularly useful in
LMICs where formal employment is relatively scarce [2]. However, finance may be a limitation
to self-employment as shown in this study [30] and the work by Heymann and colleagues [2].
Cooperative income-generation groups were observed to facilitate employment because they
allowed individuals to work without fear of discrimination among people who understand them
[32]. This assessment is corroborated by the use of sheltered workshops [50] and employment
farms [39], which have been found to be useful in vocational rehabilitation for people with mental
illness. Supported employment that fosters competitive employment for people with psychiatric
disabilities was also identified as a useful employment model in resource-poor settings [34].
Individual placement and support has been demonstrated to be very effective in HICs [12, 51],
but its applicability in African countries and other LMICs is still limited by finances and lack of
government support [2], which has also been noted in HICS [13].
The results of this study need to be interpreted with caution, taking the methodological and
contextual factors into account. First, the studies included in this study represent a very broad
spectrum, while being quite limited in number. In addition to the specific limitations of the
individual studies, the inclusion of studies from diverse populations presents particular challenges
for interpretation of the findings. Also, our study criteria excluded grey literature which may have
covered issues relating to employment that is often not considered in health care research.
There was also diversity in the terms used to describe psychiatric disability. The use of the terms
like ex-mental patient [31] and ex-residents [30] tend to suggest something different, although the
studies set out to describe persons with severe mental illness. The self-reported barriers to and
facilitators of employment are subjective and may not reflect the actual situation. In addition, most
of the studies did not compare the observed barriers to and facilitators of employment in persons
with psychiatric disabilities to the general population.
It is pertinent once again to underline the paucity of original studies that explore barriers to and
facilitators of employment for individuals with severe mental illness in Africa. The few studies
drawn upon in this review demonstrate an urgent need for focused research in this area. Perhaps
the stigma associated with mental illness extends to research in mental illness. This may be true in
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
63
4
Africa, where stigma of mental illness is rife and extended to mental health care providers.
4.6 Conclusion
The employment of people with psychiatric disabilities is essential and has both human rights
justifications and socioeconomic benefits for those affected, society and governments. The dearth
of context-relevant scientific evidence in Africa is of concern. There is a lack of evidence and
the existing evidence is highly fragmented and outdated. This gap in information would benefit
from further research on how to improve the employment rates among persons with psychiatric
disabilities in Africa and the achievement of Goal 8 of the SDGs.
Acknowledgements
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium 2013-0039. We also acknowledge
the support of Ralph de Vries of VU Medical Library in the search of articles included in the study
and of Professor David Ndetei for reviewing the initial draft.
Authors contribution
IDE, JFGB and BJR were involved in the design of the study. IDE conducted the literature search
and completed the screening and selection of articles with EVS. IDE, EVS, JFGB and BJR were
involved in data analysis. All the authors were involved in the drafting and approval of the final
manuscript.
Disclosure statement
The authors declare no conflict of interest. The abstract was presented at the 9th Consortium of
Universities of Global Health (CUGH) conference, New York, USA in March 2018.
Ethics and consent
The study protocol was approved by the Amsterdam Public Health science committee (WC2017-
011) and the Maseno University Ethics Review committee (MSU/DRPI/MUERC/00391/17).
Funding
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium 2013-0039.
Paper context
Employment of persons with psychiatric disabilities is low in Africa. This paper reviews barriers
to and facilitators of employment for such individuals in the region. Apart from overall scarcity
of data, the use of bio-psycho-social-dynamic model highlights inequality in coverage in research.
More attention is given to barriers, especially to stigma. Present analysis can serve as a roadmap,
showing existing gaps, which in turn can be used as directions for future research.
CHAPTER 4
64
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Appendix 4.1: Search Strategy
PubMed Session Results (09 Mar 2017)
1
Search Strategy PubMed Session Results (09 Mar 2017)
Search Query Items found
#4 #1 AND #2 AND #3 662
#3 "Absenteeism"[Mesh] OR "Convalescence"[Mesh] OR "Recovery of Function"[Mesh] OR "Sick Leave"[Mesh] OR "Disability Evaluation"[Mesh] OR "Work Capacity Evaluation"[Mesh] OR "Rehabilitation, Vocational"[Mesh] OR "Sickness Impact Profile"[Mesh] OR "Occupational Health"[Mesh] OR "return to work"[tiab] OR (evaluation*[tiab] AND (disability[tiab] OR work capacity[tiab])) OR "work disability"[tiab] OR "work incapacity"[tiab] OR "work incapability"[tiab] OR "work inhibition"[tiab] OR "working incapacity"[tiab] OR "medical leave"[tiab] OR "sick leave"[tiab] OR "disability leave"[tiab] OR absente*[tiab] OR "work absence"[tiab] OR "disability absence"[tiab] OR convalescen*[tiab] OR sick day*[tiab] OR illness day*[tiab] OR "recovery of function"[tiab] OR "functional recovery"[tiab] OR (recovery[ti] AND function*[ti]) OR "reintegration"[tiab] OR "reemployment"[tiab] OR "job reentry"[tiab] OR "presenteeism"[tiab] OR "sickness absence"[tiab] OR "work absenteeism"[tiab] OR "work day loss"[tiab] OR "work time loss"[tiab] OR "work productivity"[tiab] OR work function*[tiab] OR "work participation"[tiab] OR "work performance"[tiab] OR "performance at work"[tiab] OR "employment status"[tiab] OR "work status"[tiab] OR "occupational health"[tiab] OR "Sheltered Workshops"[Mesh] OR "Employment"[Mesh] OR "Work"[Mesh] OR employment[tiab] OR labor[tiab] OR work[tiab] OR working[tiab] OR workplace*[tiab] OR occupation*[tiab] OR vocation*[tiab] OR sheltered work*[tiab]
1,285,806
#2 "Mentally Ill Persons"[Mesh] OR mentally ill[tiab] OR "Mental Disorders"[Mesh:NoExp] OR severe mental[tiab] OR "Psychotic Disorders"[Mesh] OR psychoses[tiab] OR psychosis[tiab] OR psychotic[tiab] OR "Schizophrenia"[Mesh] OR schizo*[tiab] OR "Bipolar Disorder"[Mesh] OR bipolar[tiab] OR psychiatric disabilit*[tiab] OR psychosocial disabilit*[tiab] OR psycho-social disabilit*[tiab] OR psychiatric disable*[tiab] OR psychosocial disable*[tiab] OR "Depressive Disorder, Major"[Mesh] OR major depress*[tiab]
408,450
#1 "Africa"[Mesh] OR Africa*[tw] OR Algeria[tw] OR Angola[tw] OR Benin[tw] OR Botswana[tw] OR Burkina Faso[tw] OR Burundi[tw] OR Cameroon[tw] OR Cape Verde[tw] OR Central African Republic[tw] OR Chad[tw] OR Comoros[tw] OR Congo[tw] OR Cote d'Ivoire[tw] OR Djibouti[tw] OR Egypt[tw] OR Equatorial Guinea[tw] OR Eritrea[tw] OR Ethiopia[tw] OR Gabon[tw] OR Gambia[tw] OR Ghana[tw] OR Guinea[tw] OR Kenya[tw] OR Lesotho[tw] OR Liberia[tw] OR Libya[tw] OR Madagascar[tw] OR Malawi[tw] OR Mali[tw] OR Mauritania[tw] OR Mauritius[tw] OR Mayotte[tw] OR Morocco[tw] OR Mozambique[tw] OR Namibia[tw] OR Niger[tw] OR Nigeria[tw] OR Reunion[tw] OR Rwanda[tw] OR Senegal[tw] OR Seychelles[tw] OR Sierra Leone[tw] OR Somalia[tw] OR South Sudan[tw] OR Sudan[tw] OR Swaziland[tw] OR Tanzania[tw] OR Togo[tw] OR Tunisia[tw] OR Uganda[tw] OR Western Sahara[tw] OR Zambia[tw] OR Zimbabwe[tw]
571,678
662 items
("Africa"[Mesh] OR Africa*[tw] OR Algeria[tw] OR Angola[tw] OR Benin[tw] OR Botswana[tw] OR Burkina Faso[tw] OR Burundi[tw] OR
Cameroon[tw] OR Cape Verde[tw] OR Central African Republic[tw] OR Chad[tw] OR Comoros[tw] OR Congo[tw] OR Cote d'Ivoire[tw] OR
Djibouti[tw] OR Egypt[tw] OR Equatorial Guinea[tw] OR Eritrea[tw] OR Ethiopia[tw] OR Gabon[tw] OR Gambia[tw] OR Ghana[tw] OR Guinea[tw]
OR Kenya[tw] OR Lesotho[tw] OR Liberia[tw] OR Libya[tw] OR Madagascar[tw] OR Malawi[tw] OR Mali[tw] OR Mauritania[tw] OR Mauritius[tw]
OR Mayotte[tw] OR Morocco[tw] OR Mozambique[tw] OR Namibia[tw] OR Niger[tw] OR Nigeria[tw] OR Reunion[tw] OR Rwanda[tw] OR
Senegal[tw] OR Seychelles[tw] OR Sierra Leone[tw] OR Somalia[tw] OR South Sudan[tw] OR Sudan[tw] OR Swaziland[tw] OR Tanzania[tw] OR
Togo[tw] OR Tunisia[tw] OR Uganda[tw] OR Western Sahara[tw] OR Zambia[tw] OR Zimbabwe[tw]) AND ("Mentally Ill Persons"[Mesh] OR mentally
ill[tiab] OR "Mental Disorders"[Mesh:noexp] OR severe mental[tiab] OR "Psychotic Disorders"[Mesh] OR psychoses[tiab] OR psychosis[tiab]
OR psychotic[tiab] OR "Schizophrenia"[Mesh] OR schizo*[tiab] OR "Bipolar Disorder"[Mesh] OR bipolar[tiab] OR psychiatric disabilit*[tiab] OR
psychosocial disabilit*[tiab] OR psycho-social disabilit*[tiab] OR psychiatric disable*[tiab] OR psychosocial disable*[tiab] OR "Depressive Disorder,
Major"[Mesh] OR major depress*[tiab]) AND ("Absenteeism"[Mesh] OR "Convalescence"[Mesh] OR "Recovery of Function"[Mesh] OR "Sick
Leave"[Mesh] OR "Disability Evaluation"[Mesh] OR "Work Capacity Evaluation"[Mesh] OR "Rehabilitation, Vocational"[Mesh] OR "Sickness Impact
Profile"[Mesh] OR "Occupational Health"[Mesh] OR "return to work"[tiab] OR (evaluation*[tiab] AND (disability[tiab] OR work capacity[tiab]))
OR "work disability"[tiab] OR "work incapacity"[tiab] OR "work incapability"[tiab] OR "work inhibition"[tiab] OR "working incapacity"[tiab] OR
"medical leave"[tiab] OR "sick leave"[tiab] OR "disability leave"[tiab] OR absente*[tiab] OR "work absence"[tiab] OR "disability absence"[tiab] OR
convalescen*[tiab] OR sick day*[tiab] OR illness day*[tiab] OR "recovery of function"[tiab] OR "functional recovery"[tiab] OR (recovery[ti] AND
function*[ti]) OR "reintegration"[tiab] OR "reemployment"[tiab] OR "job reentry"[tiab] OR "presenteeism"[tiab] OR "sickness absence"[tiab] OR
"work absenteeism"[tiab] OR "work day loss"[tiab] OR "work time loss"[tiab] OR "work productivity"[tiab] OR work function*[tiab] OR "work
participation"[tiab] OR "work performance"[tiab] OR "performance at work"[tiab] OR "employment status"[tiab] OR "work status"[tiab] OR
"occupational health"[tiab] OR "Sheltered Workshops"[Mesh] OR "Employment"[Mesh] OR "Work"[Mesh] OR employment[tiab] OR labor[tiab]
OR work[tiab] OR working[tiab] OR workplace*[tiab] OR occupation*[tiab] OR vocation*[tiab] OR sheltered work*[tiab])
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
69
41023 items
(‘africa’/exp OR africa*:ab,ti OR algeria:ab,ti OR angola:ab,ti OR benin:ab,ti OR botswana:ab,ti OR ‘burkina faso’:ab,ti OR burundi:ab,ti OR
cameroon:ab,ti OR ‘cape verde’:ab,ti OR ‘central african republic’:ab,ti OR chad:ab,ti OR comoros:ab,ti OR congo:ab,ti OR ‘cote d ivoire’:ab,ti OR
djibouti:ab,ti OR egypt:ab,ti OR ‘equatorial guinea’:ab,ti OR eritrea:ab,ti OR ethiopia:ab,ti OR gabon:ab,ti OR gambia:ab,ti OR ghana:ab,ti OR
guinea:ab,ti OR kenya:ab,ti OR lesotho:ab,ti OR liberia:ab,ti OR libya:ab,ti OR madagascar:ab,ti OR malawi:ab,ti OR mali:ab,ti OR mauritania:ab,ti
OR mauritius:ab,ti OR mayotte:ab,ti OR morocco:ab,ti OR mozambique:ab,ti OR namibia:ab,ti OR niger:ab,ti OR nigeria:ab,ti OR reunion:ab,ti
OR rwanda:ab,ti OR senegal:ab,ti OR seychelles:ab,ti OR ‘sierra leone’:ab,ti OR somalia:ab,ti OR ‘south sudan’:ab,ti OR sudan:ab,ti OR
swaziland:ab,ti OR tanzania:ab,ti OR togo:ab,ti OR tunisia:ab,ti OR uganda:ab,ti OR ‘western sahara’:ab,ti OR zambia:ab,ti OR zimbabwe:ab,ti)
AND (‘mental patient’/exp OR ‘mentally ill’:ab,ti OR ‘mental disease’/de OR ‘severe mental’:ab,ti OR ‘psychosis’/exp OR psychoses:ab,ti OR
psychosis:ab,ti OR psychotic:ab,ti OR schizo*:ab,ti OR ‘bipolar disorder’/exp OR bipolar:ab,ti OR ‘psychiatric disabilit*’:ab,ti OR ‘psychosocial
disabilit*’:ab,ti OR ‘psycho-social disabilit*’:ab,ti OR ‘psychiatric disable*’:ab,ti OR ‘psychosocial disable*’:ab,ti OR ‘major depression’/exp OR
‘major depress*’:ab,ti) AND (‘work’/exp OR ‘convalescence’/exp OR ‘sickness impact profile’/exp OR ‘occupational health’/exp OR ‘employment’/
exp OR ‘return to work’:ab,ti OR (evaluation* AND (disability NEAR/3 ‘work capacity’):ab,ti) OR ‘work disability’:ab,ti OR ‘work incapacity’:ab,ti
OR ‘work incapability’:ab,ti OR ‘work inhibition’:ab,ti OR ‘working incapacity’:ab,ti OR ‘medical leave’:ab,ti OR ‘sick leave’:ab,ti OR ‘disability
leave’:ab,ti OR absente*:ab,ti OR ‘work absence’:ab,ti OR ‘disability absence’:ab,ti OR convalescen*:ab,ti OR ‘sick day*’:ab,ti OR ‘illness day*’:ab,ti
OR ‘recovery of function’:ab,ti OR ‘functional recovery’:ab,ti OR (recovery:ti AND function*:ti) OR reintegration:ab,ti OR reemployment:ab,ti OR
‘job reentry’:ab,ti OR presenteeism:ab,ti OR ‘sickness absence’:ab,ti OR ‘work absenteeism’:ab,ti OR ‘work day loss’:ab,ti OR ‘work time loss’:ab,ti
OR ‘work productivity’:ab,ti OR ‘work function*’:ab,ti OR ‘work participation’:ab,ti OR ‘work performance’:ab,ti OR ‘performance at work’:ab,ti OR
‘employment status’:ab,ti OR ‘work status’:ab,ti OR ‘occupational health’:ab,ti OR employment:ab,ti OR labor:ab,ti OR work:ab,ti OR working:ab,ti
OR workplace*:ab,ti OR occupation*:ab,ti OR vocation*:ab,ti OR ‘sheltered work*’:ab,ti)
Embase.com Session Results (09 Mar 2017)
3
Embase.com Session Results (09 Mar 2017)
Search Query Items found
#4 #1 AND #2 AND #3 1,023
#3 'work'/exp OR 'convalescence'/exp OR 'Sickness Impact Profile'/exp OR 'occupational health'/exp OR 'employment'/exp OR 'return to work':ab,ti OR (evaluation* AND (disability NEAR/3 'work capacity'):ab,ti) OR 'work disability':ab,ti OR 'work incapacity':ab,ti OR 'work incapability':ab,ti OR 'work inhibition':ab,ti OR 'working incapacity':ab,ti OR 'medical leave':ab,ti OR 'sick leave':ab,ti OR 'disability leave':ab,ti OR absente*:ab,ti OR 'work absence':ab,ti OR 'disability absence':ab,ti OR convalescen*:ab,ti OR 'sick day*':ab,ti OR 'illness day*':ab,ti OR 'recovery of function':ab,ti OR 'functional recovery':ab,ti OR (recovery:ti AND function*:ti) OR reintegration:ab,ti OR reemployment:ab,ti OR 'job reentry':ab,ti OR presenteeism:ab,ti OR 'sickness absence':ab,ti OR 'work absenteeism':ab,ti OR 'work day loss':ab,ti OR 'work time loss':ab,ti OR 'work productivity':ab,ti OR 'work function*':ab,ti OR 'work participation':ab,ti OR 'work performance':ab,ti OR 'performance at work':ab,ti OR 'employment status':ab,ti OR 'work status':ab,ti OR 'occupational health':ab,ti OR employment:ab,ti OR labor:ab,ti OR work:ab,ti OR working:ab,ti OR workplace*:ab,ti OR occupation*:ab,ti OR vocation*:ab,ti OR 'sheltered work*':ab,ti
1,689,072
#2 'mental patient'/exp OR 'mentally ill':ab,ti OR 'mental disease'/de OR 'severe mental':ab,ti OR 'psychosis'/exp OR psychoses:ab,ti OR psychosis:ab,ti OR psychotic:ab,ti OR schizo*:ab,ti OR 'bipolar disorder'/exp OR bipolar:ab,ti OR 'psychiatric disabilit*':ab,ti OR 'psychosocial disabilit*':ab,ti OR 'psycho-social disabilit*':ab,ti OR 'psychiatric disable*':ab,ti OR 'psychosocial disable*':ab,ti OR 'major depression'/exp OR 'major depress*':ab,ti
590,330
#1 'Africa'/exp OR Africa*:ab,ti OR Algeria:ab,ti OR Angola:ab,ti OR Benin:ab,ti OR Botswana:ab,ti OR 'Burkina Faso':ab,ti OR Burundi:ab,ti OR Cameroon:ab,ti OR 'Cape Verde':ab,ti OR 'Central African Republic':ab,ti OR Chad:ab,ti OR Comoros:ab,ti OR Congo:ab,ti OR 'Cote d Ivoire':ab,ti OR Djibouti:ab,ti OR Egypt:ab,ti OR 'Equatorial Guinea':ab,ti OR Eritrea:ab,ti OR Ethiopia:ab,ti OR Gabon:ab,ti OR Gambia:ab,ti OR Ghana:ab,ti OR Guinea:ab,ti OR Kenya:ab,ti OR Lesotho:ab,ti OR Liberia:ab,ti OR Libya:ab,ti OR Madagascar:ab,ti OR Malawi:ab,ti OR Mali:ab,ti OR Mauritania:ab,ti OR Mauritius:ab,ti OR Mayotte:ab,ti OR Morocco:ab,ti OR Mozambique:ab,ti OR Namibia:ab,ti OR Niger:ab,ti OR Nigeria:ab,ti OR Reunion:ab,ti OR Rwanda:ab,ti OR Senegal:ab,ti OR Seychelles:ab,ti OR 'Sierra Leone':ab,ti OR Somalia:ab,ti OR 'South Sudan':ab,ti OR Sudan:ab,ti OR Swaziland:ab,ti OR Tanzania:ab,ti OR Togo:ab,ti OR Tunisia:ab,ti OR Uganda:ab,ti OR 'Western Sahara':ab,ti OR Zambia:ab,ti OR Zimbabwe:ab,ti
550,791
CHAPTER 4
70
3
Embase.com Session Results (09 Mar 2017)
Search Query Items found
#4 #1 AND #2 AND #3 1,023
#3 'work'/exp OR 'convalescence'/exp OR 'Sickness Impact Profile'/exp OR 'occupational health'/exp OR 'employment'/exp OR 'return to work':ab,ti OR (evaluation* AND (disability NEAR/3 'work capacity'):ab,ti) OR 'work disability':ab,ti OR 'work incapacity':ab,ti OR 'work incapability':ab,ti OR 'work inhibition':ab,ti OR 'working incapacity':ab,ti OR 'medical leave':ab,ti OR 'sick leave':ab,ti OR 'disability leave':ab,ti OR absente*:ab,ti OR 'work absence':ab,ti OR 'disability absence':ab,ti OR convalescen*:ab,ti OR 'sick day*':ab,ti OR 'illness day*':ab,ti OR 'recovery of function':ab,ti OR 'functional recovery':ab,ti OR (recovery:ti AND function*:ti) OR reintegration:ab,ti OR reemployment:ab,ti OR 'job reentry':ab,ti OR presenteeism:ab,ti OR 'sickness absence':ab,ti OR 'work absenteeism':ab,ti OR 'work day loss':ab,ti OR 'work time loss':ab,ti OR 'work productivity':ab,ti OR 'work function*':ab,ti OR 'work participation':ab,ti OR 'work performance':ab,ti OR 'performance at work':ab,ti OR 'employment status':ab,ti OR 'work status':ab,ti OR 'occupational health':ab,ti OR employment:ab,ti OR labor:ab,ti OR work:ab,ti OR working:ab,ti OR workplace*:ab,ti OR occupation*:ab,ti OR vocation*:ab,ti OR 'sheltered work*':ab,ti
1,689,072
#2 'mental patient'/exp OR 'mentally ill':ab,ti OR 'mental disease'/de OR 'severe mental':ab,ti OR 'psychosis'/exp OR psychoses:ab,ti OR psychosis:ab,ti OR psychotic:ab,ti OR schizo*:ab,ti OR 'bipolar disorder'/exp OR bipolar:ab,ti OR 'psychiatric disabilit*':ab,ti OR 'psychosocial disabilit*':ab,ti OR 'psycho-social disabilit*':ab,ti OR 'psychiatric disable*':ab,ti OR 'psychosocial disable*':ab,ti OR 'major depression'/exp OR 'major depress*':ab,ti
590,330
#1 'Africa'/exp OR Africa*:ab,ti OR Algeria:ab,ti OR Angola:ab,ti OR Benin:ab,ti OR Botswana:ab,ti OR 'Burkina Faso':ab,ti OR Burundi:ab,ti OR Cameroon:ab,ti OR 'Cape Verde':ab,ti OR 'Central African Republic':ab,ti OR Chad:ab,ti OR Comoros:ab,ti OR Congo:ab,ti OR 'Cote d Ivoire':ab,ti OR Djibouti:ab,ti OR Egypt:ab,ti OR 'Equatorial Guinea':ab,ti OR Eritrea:ab,ti OR Ethiopia:ab,ti OR Gabon:ab,ti OR Gambia:ab,ti OR Ghana:ab,ti OR Guinea:ab,ti OR Kenya:ab,ti OR Lesotho:ab,ti OR Liberia:ab,ti OR Libya:ab,ti OR Madagascar:ab,ti OR Malawi:ab,ti OR Mali:ab,ti OR Mauritania:ab,ti OR Mauritius:ab,ti OR Mayotte:ab,ti OR Morocco:ab,ti OR Mozambique:ab,ti OR Namibia:ab,ti OR Niger:ab,ti OR Nigeria:ab,ti OR Reunion:ab,ti OR Rwanda:ab,ti OR Senegal:ab,ti OR Seychelles:ab,ti OR 'Sierra Leone':ab,ti OR Somalia:ab,ti OR 'South Sudan':ab,ti OR Sudan:ab,ti OR Swaziland:ab,ti OR Tanzania:ab,ti OR Togo:ab,ti OR Tunisia:ab,ti OR Uganda:ab,ti OR 'Western Sahara':ab,ti OR Zambia:ab,ti OR Zimbabwe:ab,ti
550,791
PsycINFO Session Results (09 Mar 2017)
735 items
( TI (Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon OR “Cape Verde” OR “Central African
Republic” OR Chad OR Comoros OR Congo OR “Cote d’Ivoire” OR Djibouti OR Egypt OR “Equatorial Guinea” OR Eritrea OR Ethiopia OR
Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR
Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles
OR “Sierra Leone” OR Somalia OR “South Sudan” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR “Western Sahara”
OR Zambia OR Zimbabwe) OR AB (Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon OR
“Cape Verde” OR “Central African Republic” OR Chad OR Comoros OR Congo OR “Cote d’Ivoire” OR Djibouti OR Egypt OR “Equatorial Guinea”
OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi
OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda
OR Senegal OR Seychelles OR “Sierra Leone” OR Somalia OR “South Sudan” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR
Uganda OR “Western Sahara” OR Zambia OR Zimbabwe) ) AND ( DE “Mental Disorders” OR DE “Psychosis” OR DE “Affective Psychosis” OR DE
“Paranoia (Psychosis)” OR DE “Reactive Psychosis” OR DE “Schizophrenia” OR DE “Acute Schizophrenia” OR DE “Catatonic Schizophrenia” OR DE
“Paranoid Schizophrenia” OR DE “Process Schizophrenia” OR DE “Schizophrenia (Disorganized Type)” OR DE “Schizophreniform Disorder” OR
DE “Undifferentiated Schizophrenia” OR DE “Bipolar Disorder” OR DE “Cyclothymic Personality” OR DE “Major Depression” OR DE “Anaclitic
Depression” OR DE “Dysthymic Disorder” OR DE “Endogenous Depression” OR DE “Late Life Depression” OR DE “Postpartum Depression” OR
DE “Reactive Depression” OR DE “Recurrent Depression” OR DE “Treatment Resistant Depression” OR TI (“mentally ill” OR “severe mental” OR
psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR “psychiatric disabilit*” OR “psychosocial disabilit*” OR “psycho-social disabilit*”
OR “psychiatric disable*” OR “psychosocial disable*” OR “major depress*”) OR AB (“mentally ill” OR “severe mental” OR psychoses OR psychosis OR
psychotic OR schizo* OR bipolar OR “psychiatric disabilit*” OR “psychosocial disabilit*” OR “psycho-social disabilit*” OR “psychiatric disable*” OR
“psychosocial disable*” OR “major depress*”) ) AND ( DE “Employee Absenteeism” OR DE “Recovery (Disorders)” OR DE “Employee Leave Benefits”
OR DE “Disability Evaluation” OR DE “Vocational Rehabilitation” OR DE “Supported Employment” OR DE “Vocational Evaluation” OR DE “Work
Adjustment Training” OR DE “Reemployment” OR DE “Occupational Health” OR DE “Work Related Illnesses” OR DE “Sheltered Workshops” OR
DE “Employment Status” OR DE “Job Performance” OR DE “Employee Efficiency” OR DE “Employee Productivity” OR DE “Job Involvement” OR
DE “Work-Life Balance” OR TI (“return to work” OR (evaluation* AND (disability OR “work capacity”)) OR “work disability” OR “work incapacity”
OR “work incapability” OR “work inhibition” OR “working incapacity” OR “medical leave” OR “sick leave” OR “disability leave” OR absente* OR “work
absence” OR “disability absence” OR convalescen* OR “sick day*” OR “illness day*” OR “recovery of function” OR “functional recovery” OR (recovery
AND function*) OR reintegration OR reemployment OR “job reentry” OR presenteeism OR “sickness absence” OR “work absenteeism” OR “work
day loss” OR “work time loss” OR “work productivity” OR “work function*” OR “work participation” OR “work performance” OR “performance at
work” OR “employment status” OR “work status” OR “occupational health” OR employment OR labor OR work OR working OR workplace* OR
occupation* OR vocation* OR “sheltered work*”) OR AB (“return to work” OR (evaluation* AND (disability OR “work capacity”)) OR “work disability”
OR “work incapacity” OR “work incapability” OR “work inhibition” OR “working incapacity” OR “medical leave” OR “sick leave” OR “disability leave”
OR absente* OR “work absence” OR “disability absence” OR convalescen* OR “sick day*” OR “illness day*” OR “recovery of function” OR “functional
recovery” OR reintegration OR reemployment OR “job reentry” OR presenteeism OR “sickness absence” OR “work absenteeism” OR “work day
loss” OR “work time loss” OR “work productivity” OR “work function*” OR “work participation” OR “work performance” OR “performance at
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
71
4
work” OR “employment status” OR “work status” OR “occupational health” OR employment OR labor OR work OR working OR workplace* OR
occupation* OR vocation* OR “sheltered work*”) )
Web of Science (Core Collection) Session Results (09 Mar 2017) (Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=All years)
7
Web of Science (Core Collection) Session Results (09 Mar 2017) (Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=All years)
Search Query Items found
#4 #1 AND #2 AND #3 456
#3 TS=("return to work" OR (evaluation* AND (disability OR "work capacity")) OR "work disability" OR "work incapacity" OR "work incapability" OR "work inhibition" OR "working incapacity" OR "medical leave" OR "sick leave" OR "disability leave" OR absente* OR "work absence" OR "disability absence" OR convalescen* OR "sick day*" OR "illness day*" OR "recovery of function" OR "functional recovery" OR (recovery AND function*) OR reintegration OR reemployment OR "job reentry" OR presenteeism OR "sickness absence" OR "work absenteeism" OR "work day loss" OR "work time loss" OR "work productivity" OR "work function*" OR "work participation" OR "work performance" OR "performance at work" OR "employment status" OR "work status" OR "occupational health" OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR "sheltered work*")
2,625,491
#2 TS=("mentally ill" OR "severe mental" OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR "psychiatric disabilit*" OR "psychosocial disabilit*" OR "psycho-social disabilit*" OR "psychiatric disable*" OR "psychosocial disable*" OR "major depress*")
371,923
#1 TS=(Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe)
832,910
456 items TS=(Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe) AND TS=("mentally ill" OR "severe mental" OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR "psychiatric disabilit*" OR "psychosocial disabilit*" OR "psycho-social disabilit*" OR "psychiatric disable*" OR "psychosocial disable*" OR "major depress*") AND TS=("return to work" OR (evaluation* AND (disability OR "work capacity")) OR "work disability" OR "work incapacity" OR "work incapability" OR "work inhibition" OR "working incapacity" OR "medical leave" OR "sick leave" OR "disability leave" OR absente* OR "work absence" OR "disability absence" OR convalescen* OR "sick day*" OR "illness day*" OR "recovery of function" OR "functional recovery" OR (recovery AND function*) OR reintegration OR reemployment OR "job reentry" OR presenteeism OR "sickness absence" OR "work absenteeism" OR "work day loss" OR "work time loss" OR "work productivity" OR "work function*" OR "work participation" OR "work performance" OR "performance at work" OR "employment status" OR "work status" OR "occupational health" OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR "sheltered work*")
456 items
TS=(Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon OR “Cape Verde” OR “Central African
Republic” OR Chad OR Comoros OR Congo OR “Cote d’Ivoire” OR Djibouti OR Egypt OR “Equatorial Guinea” OR Eritrea OR Ethiopia OR Gabon
OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius
OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR “Sierra
Leone” OR Somalia OR “South Sudan” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR “Western Sahara” OR Zambia
OR Zimbabwe) AND TS=(“mentally ill” OR “severe mental” OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR “psychiatric
disabilit*” OR “psychosocial disabilit*” OR “psycho-social disabilit*” OR “psychiatric disable*” OR “psychosocial disable*” OR “major depress*”) AND
TS=(“return to work” OR (evaluation* AND (disability OR “work capacity”)) OR “work disability” OR “work incapacity” OR “work incapability” OR
“work inhibition” OR “working incapacity” OR “medical leave” OR “sick leave” OR “disability leave” OR absente* OR “work absence” OR “disability
absence” OR convalescen* OR “sick day*” OR “illness day*” OR “recovery of function” OR “functional recovery” OR (recovery AND function*) OR
reintegration OR reemployment OR “job reentry” OR presenteeism OR “sickness absence” OR “work absenteeism” OR “work day loss” OR “work
time loss” OR “work productivity” OR “work function*” OR “work participation” OR “work performance” OR “performance at work” OR “employment
status” OR “work status” OR “occupational health” OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation*
OR “sheltered work*”)
CHAPTER 4
72
740 items
TITLE-ABS-KEY (Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon OR “Cape Verde” OR “Central
African Republic” OR Chad OR Comoros OR Congo OR “Cote d’Ivoire” OR Djibouti OR Egypt OR “Equatorial Guinea” OR Eritrea OR Ethiopia OR
Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR
Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR
“Sierra Leone” OR Somalia OR “South Sudan” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR “Western Sahara” OR
Zambia OR Zimbabwe) AND TITLE-ABS-KEY (“mentally ill” OR “severe mental” OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar
OR “psychiatric disabilit*” OR “psychosocial disabilit*” OR “psycho-social disabilit*” OR “psychiatric disable*” OR “psychosocial disable*” OR “major
depress*”) AND TITLE-ABS-KEY (“return to work” OR (evaluation* W/3 (disability OR “work capacity”)) OR “work disability” OR “work incapacity”
OR “work incapability” OR “work inhibition” OR “working incapacity” OR “medical leave” OR “sick leave” OR “disability leave” OR absente* OR “work
absence” OR “disability absence” OR convalescen* OR “sick day*” OR “illness day*” OR “recovery of function” OR “functional recovery” OR (recovery
W/3 function*) OR reintegration OR reemployment OR “job reentry” OR presenteeism OR “sickness absence” OR “work absenteeism” OR “work
day loss” OR “work time loss” OR “work productivity” OR “work function*” OR “work participation” OR “work performance” OR “performance at
work” OR “employment status” OR “work status” OR “occupational health” OR employment OR labor OR work OR working OR workplace* OR
occupation* OR vocation* OR “sheltered work*”) 5
PsycINFO Session Results (09 Mar 2017)
Search Query Items found
#4 #1 AND #2 AND #3 735
#3 DE "Employee Absenteeism" OR DE "Recovery (Disorders)" OR DE "Employee Leave Benefits" OR DE "Disability Evaluation" OR DE "Vocational Rehabilitation" OR DE "Supported Employment" OR DE "Vocational Evaluation" OR DE "Work Adjustment Training" OR DE "Reemployment" OR DE "Occupational Health" OR DE "Work Related Illnesses" OR DE "Sheltered Workshops" OR DE "Employment Status" OR DE "Job Performance" OR DE "Employee Efficiency" OR DE "Employee Productivity" OR DE "Job Involvement" OR DE "Work-Life Balance" OR TI ("return to work" OR (evaluation* AND (disability OR "work capacity")) OR "work disability" OR "work incapacity" OR "work incapability" OR "work inhibition" OR "working incapacity" OR "medical leave" OR "sick leave" OR "disability leave" OR absente* OR "work absence" OR "disability absence" OR convalescen* OR "sick day*" OR "illness day*" OR "recovery of function" OR "functional recovery" OR (recovery AND function*) OR reintegration OR reemployment OR "job reentry" OR presenteeism OR "sickness absence" OR "work absenteeism" OR "work day loss" OR "work time loss" OR "work productivity" OR "work function*" OR "work participation" OR "work performance" OR "performance at work" OR "employment status" OR "work status" OR "occupational health" OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR "sheltered work*") OR AB ("return to work" OR (evaluation* AND (disability OR "work capacity")) OR "work disability" OR "work incapacity" OR "work incapability" OR "work inhibition" OR "working incapacity" OR "medical leave" OR "sick leave" OR "disability leave" OR absente* OR "work absence" OR "disability absence" OR convalescen* OR "sick day*" OR "illness day*" OR "recovery of function" OR "functional recovery" OR reintegration OR reemployment OR "job reentry" OR presenteeism OR "sickness absence" OR "work absenteeism" OR "work day loss" OR "work time loss" OR "work productivity" OR "work function*" OR "work participation" OR "work performance" OR "performance at work" OR "employment status" OR "work status" OR "occupational health" OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR "sheltered work*")
675,680
#2 DE "Mental Disorders" OR DE "Psychosis" OR DE "Affective Psychosis" OR DE "Paranoia (Psychosis)" OR DE "Reactive Psychosis" OR DE "Schizophrenia" OR DE "Acute Schizophrenia" OR DE "Catatonic Schizophrenia" OR DE "Paranoid Schizophrenia" OR DE "Process Schizophrenia" OR DE "Schizophrenia (Disorganized Type)" OR DE "Schizophreniform Disorder" OR DE "Undifferentiated Schizophrenia" OR DE "Bipolar Disorder" OR DE "Cyclothymic Personality" OR DE "Major Depression" OR DE "Anaclitic Depression" OR DE "Dysthymic Disorder" OR DE "Endogenous Depression" OR DE "Late Life Depression" OR DE "Postpartum Depression" OR DE "Reactive Depression" OR DE "Recurrent Depression" OR DE "Treatment Resistant Depression" OR TI ("mentally ill" OR "severe mental" OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR "psychiatric disabilit*" OR "psychosocial disabilit*" OR "psycho-social disabilit*" OR "psychiatric disable*" OR "psychosocial disable*" OR "major depress*") OR AB ("mentally ill" OR "severe mental" OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR "psychiatric disabilit*" OR "psychosocial disabilit*" OR "psycho-social disabilit*" OR "psychiatric disable*" OR "psychosocial disable*" OR "major depress*")
386,976
#1 TI (Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe) OR AB (Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe)
88,673
735 items ( TI (Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe) OR AB (Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe) ) AND ( DE "Mental Disorders" OR DE "Psychosis" OR DE "Affective Psychosis" OR DE "Paranoia (Psychosis)" OR DE "Reactive Psychosis" OR DE "Schizophrenia" OR DE "Acute Schizophrenia" OR DE "Catatonic Schizophrenia" OR DE "Paranoid Schizophrenia" OR DE "Process Schizophrenia" OR DE "Schizophrenia (Disorganized Type)" OR DE "Schizophreniform Disorder" OR DE "Undifferentiated Schizophrenia" OR DE "Bipolar Disorder" OR DE "Cyclothymic Personality" OR DE "Major
Scopus Session Results (09 Mar 2017)
Barriers to and facilitators of employment for people with psychiatric disabilities in Africa
73
4
Cinahl Session Results (09 Mar 2017)
155 items
( (MH “Africa+”) OR TI (Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon OR “Cape Verde”
OR “Central African Republic” OR Chad OR Comoros OR Congo OR “Cote d’Ivoire” OR Djibouti OR Egypt OR “Equatorial Guinea” OR Eritrea
OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR
Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR
Seychelles OR “Sierra Leone” OR Somalia OR “South Sudan” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR “Western
Sahara” OR Zambia OR Zimbabwe) OR AB (Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon
OR “Cape Verde” OR “Central African Republic” OR Chad OR Comoros OR Congo OR “Cote d’Ivoire” OR Djibouti OR Egypt OR “Equatorial Guinea”
OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR
Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR
Senegal OR Seychelles OR “Sierra Leone” OR Somalia OR “South Sudan” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda
OR “Western Sahara” OR Zambia OR Zimbabwe) ) AND ( (MH “Mentally Disabled Persons”) OR (MH “Mental Disorders”) OR (MH “Psychotic
Disorders+”) OR (MH “Schizophrenia+”) OR (MH “Bipolar Disorder+”) OR TI (“mentally ill” OR “severe mental” OR psychoses OR psychosis OR
psychotic OR schizo* OR bipolar OR “psychiatric disabilit*” OR “psychosocial disabilit*” OR “psycho-social disabilit*” OR “psychiatric disable*” OR
“psychosocial disable*” OR “major depress*”) OR AB (“mentally ill” OR “severe mental” OR psychoses OR psychosis OR psychotic OR schizo* OR
bipolar OR “psychiatric disabilit*” OR “psychosocial disabilit*” OR “psycho-social disabilit*” OR “psychiatric disable*” OR “psychosocial disable*” OR
“major depress*”) ) AND ( (MH “Absenteeism”) OR (MH “Recovery”) OR (MH “Sick Leave”) OR (MH “Disability Evaluation+”) OR (MH “Rehabilitation,
Vocational+”) OR (MH “Sickness Impact Profile”) OR (MH “Occupational Health+”) OR (MH “Job Re-Entry”) OR TI (“return to work” OR (evaluation*
AND (disability OR “work capacity”)) OR “work disability” OR “work incapacity” OR “work incapability” OR “work inhibition” OR “working incapacity”
OR “medical leave” OR “sick leave” OR “disability leave” OR absente* OR “work absence” OR “disability absence” OR convalescen* OR “sick day*”
OR “illness day*” OR “recovery of function” OR “functional recovery” OR (recovery AND function*) OR reintegration OR reemployment OR “job
reentry” OR presenteeism OR “sickness absence” OR “work absenteeism” OR “work day loss” OR “work time loss” OR “work productivity” OR “work
function*” OR “work participation” OR “work performance” OR “performance at work” OR “employment status” OR “work status” OR “occupational
health” OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR “sheltered work*”) OR AB (“return to
work” OR (evaluation* AND (disability OR “work capacity”)) OR “work disability” OR “work incapacity” OR “work incapability” OR “work inhibition”
OR “working incapacity” OR “medical leave” OR “sick leave” OR “disability leave” OR absente* OR “work absence” OR “disability absence” OR
convalescen* OR “sick day*” OR “illness day*” OR “recovery of function” OR “functional recovery” OR reintegration OR reemployment OR “job
reentry” OR presenteeism OR “sickness absence” OR “work absenteeism” OR “work day loss” OR “work time loss” OR “work productivity” OR “work
function*” OR “work participation” OR “work performance” OR “performance at work” OR “employment status” OR “work status” OR “occupational
health” OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR “sheltered work*”) )
11
Cinahl Session Results (09 Mar 2017)
Search Query Items found
#4 #1 AND #2 AND #3 155
#3 (MH "Absenteeism") OR (MH "Recovery") OR (MH "Sick Leave") OR (MH "Disability Evaluation+") OR (MH "Rehabilitation, Vocational+") OR (MH "Sickness Impact Profile") OR (MH "Occupational Health+") OR (MH "Job Re-Entry") OR TI ("return to work" OR (evaluation* AND (disability OR "work capacity")) OR "work disability" OR "work incapacity" OR "work incapability" OR "work inhibition" OR "working incapacity" OR "medical leave" OR "sick leave" OR "disability leave" OR absente* OR "work absence" OR "disability absence" OR convalescen* OR "sick day*" OR "illness day*" OR "recovery of function" OR "functional recovery" OR (recovery AND function*) OR reintegration OR reemployment OR "job reentry" OR presenteeism OR "sickness absence" OR "work absenteeism" OR "work day loss" OR "work time loss" OR "work productivity" OR "work function*" OR "work participation" OR "work performance" OR "performance at work" OR "employment status" OR "work status" OR "occupational health" OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR "sheltered work*") OR AB ("return to work" OR (evaluation* AND (disability OR "work capacity")) OR "work disability" OR "work incapacity" OR "work incapability" OR "work inhibition" OR "working incapacity" OR "medical leave" OR "sick leave" OR "disability leave" OR absente* OR "work absence" OR "disability absence" OR convalescen* OR "sick day*" OR "illness day*" OR "recovery of function" OR "functional recovery" OR reintegration OR reemployment OR "job reentry" OR presenteeism OR "sickness absence" OR "work absenteeism" OR "work day loss" OR "work time loss" OR "work productivity" OR "work function*" OR "work participation" OR "work performance" OR "performance at work" OR "employment status" OR "work status" OR "occupational health" OR employment OR labor OR work OR working OR workplace* OR occupation* OR vocation* OR "sheltered work*")
265,125
#2 (MH "Mentally Disabled Persons") OR (MH "Mental Disorders") OR (MH "Psychotic Disorders+") OR (MH "Schizophrenia+") OR (MH "Bipolar Disorder+") OR TI ("mentally ill" OR "severe mental" OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR "psychiatric disabilit*" OR "psychosocial disabilit*" OR "psycho-social disabilit*" OR "psychiatric disable*" OR "psychosocial disable*" OR "major depress*") OR AB ("mentally ill" OR "severe mental" OR psychoses OR psychosis OR psychotic OR schizo* OR bipolar OR "psychiatric disabilit*" OR "psychosocial disabilit*" OR "psycho-social disabilit*" OR "psychiatric disable*" OR "psychosocial disable*" OR "major depress*")
101,863
#1 (MH "Africa+") OR TI (Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe) OR AB (Africa* OR Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Central African Republic" OR Chad OR Comoros OR Congo OR "Cote d'Ivoire" OR Djibouti OR Egypt OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR Kenya OR Lesotho OR Liberia OR Libya OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayotte OR Morocco OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion OR Rwanda OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Sudan" OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR "Western Sahara" OR Zambia OR Zimbabwe)
57,661
Ebuenyi ID, Regeer BJ, Nthenge M, Nardodkar R, Waltz M, Bunders-Aelen JF. Legal and policy
provisions for reasonable accommodation in employment of persons with mental disability in East
Africa: A review. International Journal of Law and Psychiatry. 2019 May 1;64:99-105.
Published as
LEGAL AND POLICY PROVISIONS
FOR REASONABLE ACCOMMODATION
IN EMPLOYMENT OF PERSONS WITH
MENTAL DISABILITY IN EAST AFRICA:
A REVIEW
C H A P T E R 5
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5. LEGAL AND POLICY PROVISIONS FOR REASONABLE ACCOMMODATION IN EMPLOYMENT OF PERSONS WITH MENTAL DISABILITY IN EAST AFRICA: A REVIEW
Abstract
Despite an elaborated framework on reasonable accommodations in the UN Convention on
the Rights of Persons with Disabilities (UN CRPD), persons with mental disabilities continue to
face significant limitations to employment in East Africa. The aim of our study is to explore legal
provisions related to reasonable accommodations in the employment-related laws regarding
persons with mental disabilities in East Africa, and to suggest ways to bridge the gap between
principles of international law and provisions of domestic laws. The disability, labour and human
rights laws of 18 East African countries were accessed from the database of WHO MiNDbank and
the International Labour Organisation. These laws were reviewed in the light of the framework of
Article 27 of the UN CRPD. We found that 15 (83%) of the countries in East Africa have ratified the
UN CRPD, and 12 (67%) have formulated an explicit definition of disability that includes mental
illness. Eleven countries (61%) have explicit laws mandating employers to provide reasonable
accommodations for persons with a mental disability. Eight countries (44%) have submitted a state
report to the CRPD Committee. Lack of clear and specific definition of reasonable accommodations
or the existence of vague definitions create challenges. If persons with a mental disability are to
exercise their right to inclusive and gainful employment, there is a need for legal reforms that
guarantee access to inclusive employment practices.
Keywords: Reasonable accommodation; Mental disability; East Africa; Disability discrimination;
Employment.
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77
5
5.1 Introduction
According to the World Disability Report, persons with disabilities constitute approximately 15%
of the world’s population, including between 785 and 975 million persons of working age [1].
Persons with mental disabilities, a category that includes mental disorders that have the potential
to impair social and occupational function [2], experience particularly marked challenges regarding
employment. A European Union report suggests that for persons with mental disabilities,
employment rates may be about 25% [3]. This estimate is probably high, and will vary depending on
the specific mental disability and how countries record and report (un)employment. In some cases,
persons ‘working’ in sheltered workshops for no or extremely low pay are counted as ‘employed,’
and some individuals may be counted as ‘employed’ despite working few and irregular hours
(precarious employment) [4]. Other individuals with mental disabilities may only be able to secure
part-time employment, or employment that is far below their educational level.
These challenges have informed the recommendation of reasonable accommodations, which
the UN CRPD defines as ‘necessary and appropriate modification and adjustments not imposing
a disproportionate or undue burden, where needed in a particular case, to ensure to persons
with disabilities the enjoyment or exercise on an equal basis with others, of all human rights and
fundamental freedoms’ (United Nations, 2006: Article 2), to improve inclusion of persons with
mental disabilities in work (McDowell and Fossey, 2014). In low- and middle-income countries
(LMICs), it is often unclear whether laws exist that mandate equal treatment, and the scope of such
laws varies widely [5, 6]. Also, it is not uncommon for low-income countries to ratify international
conventions without concrete plans to implement the resolutions [7].
In East Africa, persons with mental illness continue to endure employment discrimination [8].
Over 70% of employment in the region is informal, and this presents a particular challenge for
implementing policy provisions. This study has therefore been undertaken to explore legal
and policy provisions for reasonable accommodations in employment for persons with a
mental disability in East Africa, and to suggest ways to bridge the gap between the principles of
international law and provisions of domestic laws. In order to do this, following a section detailing
the methods used to carry out a review of the disability, labour and human rights laws of 18 East
African countries, we begin by discussing the concept of reasonable accommodations, and the
regional and international human rights instruments within which the right to work is codified. We
then present the results of the review, discuss these findings, and conclude, with reference to the
implications of our findings.
5.2 Methods
Review strategy
We reviewed the disability, labour and human rights laws of 18 East African countries [9] by accessing
electronic databases like the WHO MINDbank [10] and the International Labor Organisation’s
NATLEX database of national labour, social security and related human rights legislation [11]. The
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databases used for the review were chosen on account of their comprehensiveness and relevance
to the subject [12]. If disability or labor laws were not found for a specific country, we reviewed
its constitution in order to obtain data relating to reasonable accommodations in employment
for persons with mental disability. The retrieved policies and laws were then searched for terms
such as discrimination, non-discrimination and equality. Sections on employment and work in the
specific laws/policies were reviewed in-depth to minimize the risk that relevant provisions were
excluded because utilized terms differed from our search terms. This process was undertaken by
IDE and MN, and the output was reviewed by the co-authors. In addition, we obtained data from
the World Psychiatric Association (WPA) global review of laws pertaining to the right to work and
employment of persons with mental illness [12].
We reviewed the provisions of the laws in relation to Article 27 of the UN CRPD on the right to
work. We searched through the constitutional and subsidiary laws for terms relating to disability,
mental illness/disability/health, employment and reasonable accommodations (e.g. discrimination,
non-discrimination, equality).
We translated sections of the laws that were not in English, and asked a native speaker of the
language to confirm these translations. However, the availability of expert translation services was
limited, and may have affected the extent of data with respect to non-English speaking countries.
The study relied on a review of literature and data repositories of disability, labour and human
rights legislation that are available online. This may have limited our access to other national
policies and bills that could have relevant sections on reasonable accommodations for employment
of persons with mental disabilities. Also, our analysis of reasonable accommodations on
employment for persons with mental disabilities is based on what we found in national laws and the
recommendations of the UN CRPD Committee (where available), and may not reflect the actual
experiences of the persons with mental disabilities in specific countries. Also, we may have missed
provisions on reasonable accommodation that utilized terms different from the ones we used, or
practices based on case law.
Our extraction table was used to obtain the following information for each country in East Africa:
1. Status of ratification of the UN CRPD
2. Recognition of mental illness as a disability (and how mental illness was referred to)
3. Provision and forms of reasonable accommodation for persons with disability
4. Submission of a State Report to the UN CRPD Committee
5. Review of the State Report by the UN CRPD Committee (specifically regarding
recommendations related to the right to work, equality and non-discrimination by way of
recognizing access to reasonable accommodations)
We checked the country pages of the countries in WHO MINDBank to confirm whether they had
submitted a State Report to the CRPD Committee, and subsequently analyzed the review and
response of the CRPD Committee to the State Party, if one existed. For countries that have received
Legal and policy provisions for reasonable accommodation in employment
79
5
a review, we examined the recommendations of the CRPD Committee regarding country-specific
legislation and policies, and how the country has complied with the recommendations given. We
used the data from the WPA review to triangulate the data in our extraction table.
Ethical approval
The study design was approved by the Amsterdam Public Health science committee (WC2017-
011). The Maseno University (Kenya) Ethics Review committee approved the study (MSU/DRPI/
MUERC/00391/17).
5.3 Background
Gainful employment and development are interrelated, and it is well-known that disadvantaged
groups have unique needs. Indeed, the Sustainable Development Goals (SDGs) set specific targets
to achieve full and productive decent work for women and persons with disabilities by 2030 [13].
However, despite the strong provisions in international and regional human rights law that are
outlined in this section, persons with mental disabilities remain over-represented amongst the
unemployed.
The reasons are complex. Mental illness has a long history of association with prejudice, stigma
and neglect [14-16]. Key barriers to gainful employment of persons with mental disabilities include
stigma attached to mental health conditions, indirect and direct discrimination, segregation and
exclusion [17]; systemic challenges to inclusion in education [18]; the impact of social stigma on
the self-esteem of individuals with mental disabilities, and restrictive national laws based on the
medical model of disability [4].
International human rights instruments and the human right to work
In 1976 the International Covenant on Economic, Social and Cultural Rights (ICESCR) [19] came
into force. Article 7 of the ICESR recognizes the right to work. While the ICESCR does not explicitly
refer to persons with disabilities, General Comment No. 5 on persons with disabilities and General
Comment No. 23 on the right to just and favourable conditions of work [20, 21] reiterate the right
to favourable working conditions for all, without discrimination, including on the basis of disability.
Sections are devoted to safeguarding the rights of persons with mental disabilities specifically
[19]. In 1993, 22 standard rules on equalization of opportunities for persons with disabilities were
adopted by the UN General Assembly to further protect the rights of persons with disabilities [22].
In 2006, the UN General Assembly adopted the CRPD, which was opened for ratification in 2007.
To date, about 177 countries have signed and ratified the CRPD [23]. The CRPD is guided by a
set of principles that include non-discrimination, equality of opportunity, and full and effective
participation in society. Further, the UN CRPD explicitly defines reasonable accommodations,
and creates linkages between discrimination on the basis of mental disability, reasonable
accommodations, and the right to work. To this end, Article 1 of the UN CRPD defines persons
with disabilities to ‘include those who have long-term physical, mental, intellectual or sensory
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impairments, which in interaction with various barriers may hinder their full and effective
participation in society on an equal basis with others.’ The preamble of the UN CRPD recognizes
that discrimination against any person on basis of disability is a violation of the inherent dignity and
worth of the human person [24]. In defining discrimination on the basis of disability, the UN CRPD
recognizes that discrimination includes denial of reasonable accommodations. Article 27 (1)(i) of
the UN CRPD recognizes the right to work for persons with mental disabilities.
National laws, regional instruments and the human right to work
State Parties have an obligation, as provided under general obligations and Article 5 of the UN
CRPD, to take all appropriate measures to modify or abolish existing laws, regulations, customs
and practices that constitute discrimination against persons with disabilities in the workplace. In
order to monitor compliance with these provisions, Article 35 of the UN CRPD requires State
Parties to submit reports of the progress made in relation to the CRPD two years after the policy
ratification.
The right to work is further recognized in the African Charter on Human and Peoples’ Rights
[25] and the recently adopted Protocol to the African Charter on Human and Peoples’ Rights on
the Rights of Persons with Disabilities [26]. Like the UN CRPD, the African Disability Protocol
specifically obligates the State Parties to ensure that employers, both private and public, provide
reasonable accommodations to persons with disabilities in the workplace.
Research suggests that even when relevant laws and international policies exist, their
implementation and usefulness for persons with disabilities varies by country and disability type
[27]. Country-specific disability and labor laws tend to call for equal opportunities in employment,
but with varying practical implementations and usefulness for persons with disabilities, and
especially for persons with mental disabilities [12, 28]. Non-inclusive definitions of disability
in national legal and policy documents, and poor representation of persons with persistent and
disabling mental illness in disabled persons’ organizations that influence legislation and policy, are
common occurrences [29].
The importance and usefulness of clear, inclusive legal provisions regarding employment for
persons with mental disabilities have been demonstrated in high-income countries. Most
importantly, enforcement mechanisms have proven to be pivotal to achieving policy provisions [28].
This is exemplified by the Canadian Human Rights Act [30], the Australian 2010–2020 National
Disability Strategy [31]; the Equality Act 2010 in the United Kingdom [32], and disability and non-
discrimination law in the European Union [33], all of which can be used as the basis for individual
discrimination claims. However, even in these countries, participation in work by persons with
mental disabilities remains low, and often requires recourse to employment tribunals or courts.
Inclusive definition of disability
It is recognized that how disability is defined can limit or extend the availability of legal remedies,
and that people with mental disabilities have often been less favourably treated under disability
Legal and policy provisions for reasonable accommodation in employment
81
5
rights laws, including the ADA (Americans with Disability Act) [34]. The inclusive definition of
disability that is explicit in both the Canadian Human Rights Act [30] and the Australian 2010-
2012 National Disability Strategy [31], recognizing mental disability alongside physical disability,
has had huge implications for persons with mental disabilities who wish to pursue their right to
work.
Inclusive definition of disability under the law forms the focus of Section 4 of this review, which
concerns similar laws in East Africa.
Reasonable accommodations
The term ‘reasonable accommodation(s)’ appears seven times in the UN CRPD. Under these
provisions, which include Article 5: the right to equality and non-discrimination, Article 14: The
right to liberty and security of the person, Article 24: The right to education, and Article 27: The
right to work and employment [24], reasonable accommodation is interpreted as a precondition to
enjoyment of specific rights. Of course, the scope of reasonable accommodation is large, and not
specific to mental disability. However, provisions that ensure equality and non-discrimination on
the basis of disability need to explicitly include provisions for persons with mental illness in order
to overcome the higher level of disadvantage experienced by this group.
State Parties that have signed the UN CRPD are therefore mandated to ensure that reasonable
accommodations are provided to persons with mental disabilities in the workplace. The aim of any
accommodation measure in the workplace is to enable the person for whom it is implemented to
participate fully and equally in working life [35]. Denial of reasonable accommodations therefore
constitutes discrimination on the basis of disability (United Nations, 2006: Article 2). Globally,
numerous legal and policy provisions reaffirm the right to reasonable accommodations for
persons with disabilities in all spheres of life [36, 37]. The Americans with Disability Act (ADA)
[38] represented one of the first times the concept of reasonable accommodations was applied to
disability within a legal framework, and later the European Union became one of the first regional
bodies to adopt the concept through its Council Directive 2000/78 [39]. It has been incorporated
into international human rights policy provisions, many country-specific disability laws, and also
some general national legislation regarding employment [12, 28].
A scoping review on workplace accommodations for persons with mental illness identified various
examples of reasonable workplace accommodations, for instance flexible scheduling/reduced
hours, modified training and supervision, and modified job duties/descriptions [37]. Current
guidance for employers from the U.S. Equal Employment Opportunity Commission (EEOC)
includes additional modifications, such as time to attend therapy appointments, a quiet work
space, or permission to work from home [40]. The lack of reasonable accommodations in
employment is often cited as a primary cause for high unemployment levels amongst people
with disabilities [41], indicating that reasonable accommodation measures are essential to
enjoyment of basic rights, including the right to employment.
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5.4 Results
Status of UN CRPD ratification and inclusion of mental illness in the definition of disability
We found that 15 (83%) of the 18 countries in the East Africa region have ratified the UN CRPD
(see Table 5.1). Twelve (67%) of the countries have laws that recognize mental illness as a disability
(see Table 5.2). For example, in Uganda, Article 2 of the Persons with Disabilities Act 2006
recognizes that mental impairment can affect activities of daily living and result in disability [42].
Similarly, in Seychelles, the National Council for Disabled Persons Act recognizes mental illness as
a form of disability [43]. In the remaining six countries, it was unclear whether mental illness was
included in the definition of disability, as there was no reference to mental illness in the description
of disabilities.
It is also pertinent to point out that most of the laws still use derogatory terms such as ‘unsound
mind’ or ‘mad’ to refer to mental illness, including the laws of some countries that explicitly include
mental illness as a disability [44]. For instance, in the Ugandan constitution, one of the conditions
under which a person may be deprived of personal liberty includes “in the case of a person who is,
or is reasonably suspected to be, of unsound mind or addicted to drugs or alcohol…”[45]. Similarly,
in the Kenyan constitution, one of the reasons for voter eligibility requires that the person “is not
declared to be of unsound mind” [46].Table 1: Countries that have signed / ratified the CRPD
Status N (%)
Ratified 15 (83%)
Signed but not yet ratified 1 (6%)
Neither signed nor ratified 2 (11%)
Table 2: Countries that explicitly define/recognize mental illness as a disability
Status N (%)
Yes (mental illness is included in the definition of disability) 12 (67%)
Unclear (it is unclear whether mental illness is included in the definition of disability)
6 (33%)
Table 1: Countries that have signed / ratified the CRPD
Status N (%)
Ratified 15 (83%)
Signed but not yet ratified 1 (6%)
Neither signed nor ratified 2 (11%)
Table 2: Countries that explicitly define/recognize mental illness as a disability
Status N (%)
Yes (mental illness is included in the definition of disability) 12 (67%)
Unclear (it is unclear whether mental illness is included in the definition of disability)
6 (33%)
Table 5.1: Countries that have signed / ratified the CRPD
Table 5.2: Countries that explicitly define/recognize mental illness as a disability
Defining reasonable accommodations in national laws
We observed a lack of explicit definitions of reasonable accommodations, and incomplete
recognition that denial of reasonable accommodations is disability-based discrimination. Only 11
(61%) of the countries have issued recommendations to employers on reasonable accommodations
for employment of persons with disabilities that include mental disabilities (see Table 5.3). For
instance, the Disability Act in Kenya and the Disability Act of Malawi recommend a barrier-free
and disability-friendly environment for employment of persons with disabilities [47, 48]. In the
other seven countries, recommendations on reasonable accommodations are given, but it is
unclear whether persons with mental disabilities are included in such recommendations based on
Legal and policy provisions for reasonable accommodation in employment
83
5
their definition of disability.
Some countries have disability laws that incentivize the inclusion of persons with disabilities in
employment. For example, Kenya’s law guarantees a 25% tax incentive for employers of persons
with disabilities [47]. Similarly, in Uganda the Persons with Disabilities Act of 2006 ensures a 15%
tax incentive for employers of persons with disabilities [42]. These incentives apply to employers of
persons with disabilities in general, and not to persons with mental disabilities alone. In countries
where mental illness is accepted as a form of disability, it may be inferred that these incentives
would be extended to employers of persons with mental disabilities. One function of such
incentives is to cover the cost of reasonable accommodationsTable 3: Countries with recommendations on reasonable accommodations in employment of persons with mental disabilities
Status N (%)
Yes (clear recommendations for reasonable accommodations in employment of persons with mental disabilities in the workplace)
11 (61%)
Unclear (it is unclear whether the laws and policies recommend reasonable accommodations in the workplace and/or in relation to employment of persons with a mental disability)
7 (39%)
Table 4: Countries that have submitted a State Report to the CRPD Committee
Status N (%)
Yes (have submitted a State report to the CRPD committee) 8 (44%)*
No (have not submitted a State Report to the CRPD committee) 10 (56%)
*Out of the 8 countries that submitted a State Report, only 4 (22%) have been reviewed.
Table 5.3: Countries with recommendations on reasonable accommodations in employment of persons with
mental disabilities
State reports on compliance with UN CRPD
Eight of the countries have submitted a State Report to the UN CRPD committee (see Table 5.4),
and of these, four State Reports have been reviewed. We do not know why the State Reports of
the other four countries have not been reviewed by the CRPD Committee. The review of State
Reports serves as a way of monitoring compliance of State Parties with the recommendations of
the CRPD Committee, including the alignment of their national laws to the UN CRPD.
The countries whose State Reports have been reviewed (Ethiopia, Kenya, Mauritius and Uganda)
received similar patterns of recommendations from the UN CRPD Committee. The recurring
recommendations in the concluding observations of the UN CRPD Committee for the State
Parties whose reports were reviewed were removal of derogatory references to mental illness in
national laws and policies, and addressing the poor rates of employment for persons with mental
or psychosocial disabilities [44, 49-51].
In Kenya, the employment rate for persons with disabilities was noted as 1% [44]. In Mauritius,
the committee concluded by writing that only 3% of persons with disabilities are employed, and
recommended reasonable accommodations in employment plus a movement from sheltered
employment to open/competitive employment for persons with disabilities [51]. In Ethiopia and
Uganda, the committee noted the absence of affirmative action to support the employment of
persons with disabilities [49].
The CRPD Committee also highlighted the non-involvement of civil society in the preparation of
the four reviewed Reports. Article 33 (3) of the CRPD confers a monitoring role onto civil society
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5.5 Discussion
Our study reveals that ratification of the UN CRPD does not always mean that its key provisions
are quickly reflected in country-specific legislation. This observation is highlighted by the non-
inclusive definitions of disability found in the laws of several countries that have ratified the UN
CRPD. A report by the NGO Disability Studies in Nederland suggests that non-inclusive definitions
of disability form a key barrier to persons with mental disabilities enjoying the right to reasonable
accommodations in the workplace [4]. In our study, the law-to-practice gap is even larger when the
rate of ratification (83%) is compared to only 44% compliance with submission of a State Report
to the UN CRPD Committee, which triggers monitoring of compliance by State Parties, and is also
an indicator of the fulfilment of their immediate and progressive obligations. These discrepancies
between national and international legislation are likely markers of even larger gaps between
national laws and practice, as was highlighted in a recent study on disability policy in Africa [52].
The lack of clarity on whether mental illness is included in the definition of disability in six countries
raises concerns. Explicit inclusion is necessary to bring parity even within the disability sector,
and also to facilitate access to other employment-related rights, such as insurance, medical leave
or obtaining a disability certificate [53]. An inclusive definition of disability in legal documents is
relevant for implementation of reasonable accommodations for persons with mental disabilities in
the workplace and in other sectors of life. A narrow definition of disability that excludes persons
with mental illness implies that such individuals are unlikely to benefit from government welfare
packages for persons with disabilities, an attitude that has been previously reported in Kenya [29].
Also, employers may not accept having to provide workplace accommodations for persons with
mental illness in countries where mental illness is not recognized as a disability.
Our study reveals a divergence between the ratification of the UN CRPD and changes to country-
specific legislation that would ensure actualization of the treaty. This is also observed in the 22%
organizations regarding the implementation of the convention by State Parties [24]. In addition
to having a potential role in official monitoring of UN CRPD compliance, in many countries civil
society organizations carry out independent investigations and issue ‘shadow reports’, typically
when it is perceived that the official government report is less than honest.
In the disability, labor and national laws examined, it was unclear whether the countries perceive
reasonable accommodations as a progressive or immediate obligation, and there is an overall lack
of specific frameworks to align national policies to the recommendations of the UN CRPD.
Table 3: Countries with recommendations on reasonable accommodations in employment of persons with mental disabilities
Status N (%)
Yes (clear recommendations for reasonable accommodations in employment of persons with mental disabilities in the workplace)
11 (61%)
Unclear (it is unclear whether the laws and policies recommend reasonable accommodations in the workplace and/or in relation to employment of persons with a mental disability)
7 (39%)
Table 4: Countries that have submitted a State Report to the CRPD Committee
Status N (%)
Yes (have submitted a State report to the CRPD committee) 8 (44%)*
No (have not submitted a State Report to the CRPD committee) 10 (56%)
*Out of the 8 countries that submitted a State Report, only 4 (22%) have been reviewed.
Table 5.4: Countries that have submitted a State Report to the CRPD Committee
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of the countries that have received recommendations from the CRPD Committee. There is an
obvious failure of State Parties to adhere through practice to the recommendations of the CRPD
Committee. The persistence of discrimination and the use of derogatory terms regarding persons
with mental disabilities are worrisome, and suggest a correlation between stigma attached to
mental disabilities and the drafting of legislation. Other studies indicate an association between
mental disability, stigma and the absence of reasonable accommodations in employment of persons
with mental disability [12, 54]. Enforcement of national legislation on reasonable accommodation
is important for the realization of inclusive and equitable employment for persons with mental
disabilities. The employment rate of 1% for all persons with disabilities in Kenya documented in
the CRPD Committee report [44] implies that for persons with mental disabilities, the rate is a
fraction of 1%.
Enforcement of available laws and policies is pivotal to achievement of immediate obligations
related to other basic needs, like health, education and shelter that persons with mental disabilities
require to function in employment [15, 55]. Reasonable accommodations in education and health
are absolutely essential for employment of persons with mental disabilities [10]. It is hence not
surprising that the UN CRPD Committee recommended national coverage of health insurance for
persons with disabilities in Uganda [50]. In Kenya, a report published by the Users and Survivors
of Psychiatry Kenya makes a case for the realization of the right to health, and highlights the many
deficiencies of their country’s health system [29].
The duty to provide reasonable accommodations is an ex nunc duty, which means that it is
enforceable from the moment an individual with an impairment needs it in a given situation, for
example in a workplace or school, in order to enjoy her or his rights on an equal basis in a particular
context [56, 57]. Hence, reasonable accommodation is not the mere provision of accessibility (an
ex ante duty), but entails individualized measures negotiated with the affected individual, and
sometimes initiated by the duty bearer when recognized as relevant to overcome barriers to the
exercise of rights by a person with a disability [57]. Interestingly, there is evidence that reasonable
accommodations for persons with psychiatric disabilities do not cost the employer so much [58]. A
range of accommodation measures, including flexible and alternative working arrangements, can
be provided at low cost [35]. We acknowledge that some of the reviewed laws and policies may
have provisions related to reasonable accommodations that we may have missed. Also, we may
have missed practices based on precedents set by court cases.
5.6 Conclusion and recommendations
The provision of reasonable accommodations in employment for persons with a mental disability
is a human right, as guaranteed in the UN CRPD. However, accessing this right remains extremely
difficult for people living in East Africa. Our research documents a gap between ratification of the
UN CRPD and its translation into legal and policy provisions for reasonable accommodations in
employment in respective countries. In most cases, inclusion of reasonable accommodations and
recognition of the denial of reasonable accommodations as discrimination is lacking in East Africa.
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In addition, much of the literature, including legal and policy advice, is geared towards formal
employment. Companies with HR departments, formal contracts, and diversity policies find it
easier to implement the kinds of reasonable adjustments that are typically given as examples of
good practice. In East Africa, however, new ways of thinking, new ways to reach and convince small,
informal employers, and methods of providing support for those who live by daily labour or self-
employment are needed.
Translating principles of international human rights into real-world practice is fundamental to
the enjoyment of the right to work for persons with mental disabilities. It is essential for states
to review their laws more carefully, including employment laws and definitions of disability, to
ensure that they are in line with the UN CRPD. It is further crucial for states to create awareness
about the requirement to provide reasonable accommodations in employment amongst different
stakeholders, including employers in both the private and public sector, and to take steps to
eliminate mental disability stigma. Persons with mental disabilities and their representative
organizations must be actively involved in all these processes to guard against discrimination,
and to generate helpful examples of how reasonable accommodations can make a difference in a
variety of work situations. It is our recommendation that future studies on this subject review the
actual implementation of laws, and the impact of reasonable accommodations on the enjoyment of
the right to work by persons with a mental disability
Authors and contributors
IDE, BJR, and JFGB designed the study. IDE collected the data, which was analyzed with MN, RN
and MW. IDE wrote the initial draft, which was reviewed with BJR, JFGB, MN, RN and MW. All
authors approved the final version of the manuscript for submission.
Funding
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium FPA 2013-0039 (SGA2016-1346).
Acknowledgements
We are grateful to Prof. Michael Stein for his review of the initial draft of the manuscript and his
suggestions. We thank Dr. Soumitra Pathare and Dr. Dinesh Bhugra for sharing data from the
World Psychiatric Association (WPA) global review of laws pertaining to the right to work and
employment of persons with mental illness.
Competing interests
None
Prior presentation
Presented as an abstract at the International Commission on Occupational Health (ICOH)
conference, May 2018 (Dublin, Ireland).
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Published asEbuenyi ID, Guxens M, Ombati E, Bunders-Aelen JFG, Regeer BJ. Employability of Persons
With Mental Disability: Understanding Lived Experiences in Kenya. Frontiers in Psychiatry.
2019;10(539).
EMPLOYABILITY OF PERSONS WITH
MENTAL DISABILITY: UNDERSTANDING
LIVED EXPERIENCES IN KENYA
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6. EMPLOYABILITY OF PERSONS WITH MENTAL DISABILITY: UNDERSTANDING LIVED EXPERIENCES IN KENYA Abstract
Introduction: Globally, mental illness affects social and occupational functioning. We aimed
to highlight the barriers to employment experienced by persons with mental disabilities in
Kenya and how they manage to find work against all the odds.
Materials and Methods: Using a mixed-method study design, we purposely sampled persons with
mental illness through networks of persons with psychosocial disabilities (Users and Survivors of
Psychiatry and African Mental Health Foundation, Kenya). Qualitative data was obtained through
in-depth interviews (n=14) and four focus group discussions (n=30) while a researcher-designed
questionnaire was used to obtain quantitative data (n=72).
Results: We identified five major clusters of barriers to employment: mental illness factors, social
exclusion and stigma, work identity crisis, non-accommodative environment and socioeconomic
status. Factors that facilitated employment include self-awareness and acceptance, self-
employment, provision of reasonable accommodation, improved health services, addressing
discriminatory laws and practices and social development programmes and support. Participants
considered psychiatric illness the highest barrier to employment (63.2%), while supportive family/
friends were considered the highest facilitator of employment (54.5%).
Conclusion: The employment experiences of persons with mental disabilities are influenced by
various interrelated factors in their social environment. Proactive social support and affirmative
action by government may improve their employment opportunities and quality of life.
Keywords: employability, self-employment, social support, psychosocial disability, Kenya, East
Africa
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6.1 Introduction
Globally, persons with disabilities often experience stigma and social exclusion, which negatively
affects major areas of life including access to health care, education, relationships, employment
and social participation [1-6]. Studies suggest a two-way relationship between mental illness and
poverty and show how they reinforce each other [1, 7].
For the individual with mental illness, this is not only a source of disability [8] but also a limitation
to obtaining relevant help. This is because mental illness is often not considered as a disability
and individuals affected by it experienced both overt and covert discrimination in employment [9,
10] compared to persons with other disabilities. The discrimination and stigma associated with
mental illness often affects the decision to disclose, which makes it impossible to obtain reasonable
accommodation in education and employment. The dilemma of disclosure and identifying as an
individual with mental or psychosocial disability also limits employment opportunities [11-13]. In
high income countries, supported employment practices for vocational rehabilitation of individuals
with mental disabilities are associated with improved employment outcomes [14-17]. Evidence
of the usefulness of supported employment and modified work environment for the benefit of
individuals with mental illness have been document in the UK, USA and Netherlands [14-17]. Also,
self-employment (where an individual works for self or owns the business) as a useful employment
option for persons with psychiatric disabilities have been reported in the USA [18]. There are few
examples of vocational rehabilitation for persons with mental illness in low income settings in
Africa [19]. In low-income settings, proximal challenges of interrupted education and poverty also
affect their ability to set up their own business, thus ruling out the self-employment that may have
served as an alternative to elusive formal employment [20, 21].
Inclusive employment is a human right so persons with mental disability have the right to
employment as recommended by the United Nations Convention on the Rights of Persons with
Disabilities (CRPD) [22]. Equity and social justice requires governments and employers to guarantee
equal employment opportunities for persons with mental disability devoid of discrimination on
account of illness [21]. Although the World Health Organization (WHO) recommends competitive
employment through Individual Placement and Support (IPS) for employment of persons with
severe mental illness [23], such mechanisms are often unavailable in low-income settings. In a
review by Mills, inclusion of mental health as a global priority is relevant to economic development
and achievement of the Sustainable Development Goals (SDGs) [2].
However, in low- and middle-income countries where social welfare is almost non-existent,
individuals with mental disabilities lack the kind of support provided by governments in high-
income counties [24]. The Kenya National Commission on Human Rights report on mental health
highlights the complex challenges facing persons with mental illness in Kenya [25]. The magnitude
of the challenges of employment faced by persons with mental disabilities are sometimes unknown
or ignored. In Kenya, the number of persons with mental disabilities continues to rise and with
an increased call on policy-makers to address these issues [9]. Article 27 of the CRPD bestows
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on state parties the responsibility to promote inclusive employment and opportunities to enable
persons with disabilities to realize their right to work [22]. This is the central idea of the social
model of disability that considers the social environment as responsible for the impact of disability
on the individual [10]. The social model embodies a critical response to the medical model, which
perceives the person with disabilities as someone with dysfunctions that need to be resolved by
making changes to the person (e.g. medical treatment, addressing an impairment). It carries the
idea of the person with a disability as deviating from the norm which should be mitigated by making
changes to the individual rather than to social norms [26]. The social model has been strengthened
by the rights-based disability movement, which advocates for the rights of people with a disability
to participate in society on an equal basis. The CRPD resonates with the social and the rights-
based model [27]. Yet, there have also been calls for exploration of the role of the individual with
disabilities on their return to work [28, 29].
Few studies have explored the employment experience of persons with mental disabilities in
Kenya or looked into the interplay between societal and individual factors from the perspective of
persons with mental disabilities. We have explored the perspectives of other stakeholders such as
employers, mental healthcare providers, workers in disabled persons/mental health organisations
in separate articles [30, 31]. This study aims to highlight the individual and environmental barriers
to employment experienced by persons with mental disabilities in Kenya, but also how they, as
individuals, supported by their environment, manage against all the odds to find employment. This
study is important because it offers the actual experiences of persons with mental disabilities and
the factors that enabled them to overcome the many challenges on their path.
6.2 Materials and Methods
Study design, population and setting
We used a sequential mixed-method design [32] whereby we collected qualitative and quantitative
data in the first and second phase respectively. Study participants were recruited through
two networks of persons with mental/psychosocial disabilities; namely Users and Survivors of
Psychiatry (USP) and the African Mental Health Foundation (AMHF). In this study, we alternated
mental with psychosocial disabilities, the term preferred by mental illness rights groups. The USP
is a support network of persons with psychosocial disabilities in Kenya, while AMHF is a non-
governmental organization (NGO) dedicated to research and services related to mental health in
Kenya. All individuals involved in the study were clinically stable and were not actively ill at the time
of the study.
Sampling
The study participants were invited to participate in the study through the networks of USP and
AMHF and those who consented were invited for the qualitative study (in-depth interview or
Focus Group Discussions (FGDs)) and quantitative study. A total of 14 individuals participated in
the in-depth interviews while four FGDs with a total of 30 individuals were conducted. A total
of 72 individuals participated in the quantitative study (20% of individuals overlap between both
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studies).
Data collection
In the qualitative study, we sought to explore the lived experiences of persons with psychosocial
disability and how they were able to find employment. The interviews were conducted by IDE and a
master’s student after participants were provided with the study information. Interview locations
included the office of AMHF or any other location chosen by the participant. Consent was obtained
from all study participants. Three of the four FGDs were conducted by trained research assistants
in Swahili and translated to English; while one FGD was conducted in English by IDE. The interviews
were semi-structured and explored both perceived barriers and facilitators of employment for
persons with mental disabilities. The FGDs explored the same themes as the interviews but sought
to generate a consensus and a validation of the themes identified in the interviews. The interviews
and FGDs lasted for 30-60 minutes and were recorded and subsequently transcribed verbatim.
Data saturation was deemed to have been achieved when no new information was obtained from
the interviews and FGDs [33, 34].
The quantitative study sought to explore the factors that hinder or facilitate the employment of
persons with mental disabilities in a larger group of respondents. The results from the qualitative
study were used in the design of a questionnaire which was pre-tested by the researchers and
sought to validate the findings of the qualitative study. The questionnaires were administered
in English or Swahili, the two official languages in Kenya. The questionnaire documented a
sociodemographic of study participants, and perceived barriers to and facilitators of their
opportunities of employment. The social function of the study population was measured using the
Social Functioning Questionnaire (SFQ) [35]. The complete details of the SFQ has previously been
published [36].
Data analysis and integration
The qualitative data was imported into Atlas.ti version 8 and analysed thematically [37]. The
qualitative data was independently coded by IDE and EO and the resulting coding scheme was
shared with MG, JFGB-A and BJR. All authors subsequently discussed the coding scheme after
which the final themes emerged. The quantitative analysis was conducted using IBM SPSS version
23 (IBM, New York). Descriptive statistics was used to explore the sociodemographic characteristics
of the study participants and their perceived barriers to and facilitators of employment. We used
an iterative analytical process to ensure integration of the qualitative and quantitative data
throughout the analysis. In addition, the study participants were involved in the analysis and also
collaborated in the study to ensure validity and acceptance of the findings [38]. The study results
and their analysis were shared with some members of USP, one of whom participated in preparing
the manuscript.
Ethics
The approval for the study design was granted by Amsterdam Public Health (WC2017-011) and
ethical approval was obtained from Maseno University Ethics Review Committee (MSU/DRPI/
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MUERC/00391/17). Written Informed consent was obtained from all study participants.
6.3 Results
Characteristics of Study Participants
In the qualitative study, FGD1 and 2 were mixed groups of men and women, while FGD3 and
FGD4 comprised only men and only women respectively. Table 6.1 shows the demographic
characteristics of participants who completed the questionnaires of the quantitative study. We
recorded a response rate of 60%. The mean age of the study participants is 40.0 years and 45.8%
were 41 years and above, most were women (69.4%) and 70.8% were unmarried.
Table 1. Socio-demographic characteristics of the participants (N=72)
Variable Categories Distribution N (%)
Age 30 years and below 10 (13.9)
31-40 years 29 (40.3)
41 years and above 33 (45.8)
Age in years Mean, Median, Range 40.0; 38.8; 23-63
Sex Male 22 (30.6)
Female 50 (69.4)
Marital status Unmarried 51 (70.8)
Married 21 (29.2)
Number of children None 16 (23.5)
With children 52 (76.5)
Missing 4
Education level Primary and below 32 (45.1)
Secondary and above 39 (54.9)
Missing 1
Type of mental disability diagnosed
Schizophrenia and other psychotic disorders 12 (18.8)
Depression 20 (31.3)
Depression and other comorbid conditions 19 (29.7)
Bipolar disorder 13 (20.3)
Missing 8
Employment status Unemployed 40 (55.6)
Employed* 32 (44.4)
Job satisfaction (among the employed)
Satisfied 15 (46.9)
Not satisfied 17 (53.1)
Interested to be employed Yes 53 (76.8)
No 16 (23.2)
Missing 3
*15 of the 32 employed participants were self-employed [36].
Table 6.1: Socio-demographic characteristics of the participants (N=72)
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Regarding the mental illness types, depression was the highest self-reported diagnosis (31.3%)
while schizophrenia and other psychotic disorders was the least (18.8%). The mean social
functioning score of study participants was 12.8 (SD=5.7 and a significant association was noted
between impaired social functioning and unemployment [14.0 vs. 11.2 (p = 0.037)] [36]. Over half
were unemployed (55.6%) and of the 44.4% that were employed, half were self-employed. Slightly
more than half of those employed were not satisfied with their job and 73.6% of all respondents
were interested in employment.
Experiences of mental disability and barriers to Employment opportunities
In this section, we present two case studies (Box 6.1) that highlight the experience of the
participants and subsequently discuss the major themes that capture their experience and barriers
to employment. It is pertinent to state that the cases are mixed and do not reflect the experience
of any specific individual.
Both Nyawira and Bahati share the impacts of mental illness on their functioning; they go through
periods of not being able to get up in the morning and losing jobs because of it. Periods of mania, and
the side-effects of medication, also contributed to losing employment. Besides the direct effects
of the illness, the lack of understanding and support from, and even the demeaning attitude of,
their family might be expected to block the route towards (self) acceptance and developing coping
strategies. Both cases also show the perpetual effects of the illness on employability – in Bahati’ s
case by having to take a break from his education, and in Nyawira’ s case by the series of short jobs
and not being able to build a career because of it. She says:
Because of that cycle of getting a job working briefly, resigning, looking for another job, one of
the things that happens is that you can’t build your career. Because you’re never in a place long
enough, it’s very hard to advance in terms of roles, responsibilities, how much you earn, benefits
you get from your employer. […] You find that at 31, 32 you have not built anything with your life
and yet the people who you were in college with, have done quite well for themselves and yet, you
may have had better opportunities than they did.
Finally, not being able to disclose to the employer means no chance of the workplace accommodating
the person’s abilities, and limits opportunities.
The other study participants shared similar experiences of mental illness affecting their
employment opportunities. The perpetuating factors of the mental illness itself, social exclusion and
stigma, resulting in work identity crisis, as well as a non-accommodating environment clearly came to
the fore. Further, we found socioeconomic status to be an underlying factor hampering the other
factors that affected employability.
Mental illness factors
The experience of mental illness by most of the study participants was regarded as complex and
limiting. The fluctuating nature of mental illness meant that most of them had their lives and
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daily activities interrupted and were taken over by both the illness and the side-effects of their
medications. These side-effects limited both their education and socioeconomic activities and thus
formed barriers to employment opportunities. Describing the effect of medications on his ability
to work, one participant declared: ‘You see, at times when I take my medication, I become a bit slow
and sluggish and so it affects my work. So, every time at [my] work [place] and at school when I need to
work overnight I don’t take my medication’ (PWMD5_Man). The side-effects of the medication thus
also affected adherence to treatment. Overall, participants were unhappy about the mental health
services which they felt were poor and affected their health care and wellbeing. They perceived
their experience of mental illness to reflect the poor mental health services in their setting. Most
participants despised the national referral hospital and some declared they would rather avoid it.
If the government cares about Mental Health, they would upgrade the [National Referral
Psychiatric] Hospital. It has the poorest conditions and patients say like they are in hell. I have been
there as well. You know patients sleep on the floor, they pee everywhere. There is loo everywhere,
Case Study 1 Case Study 2
This is the story of Nyawira, a 43-year-old woman who lives
in Nairobi and was diagnosed with bipolar disorder seven years ago. She describes how it has been very hard for her to
keep a job, especially before she was diagnosed. ‘I [would] just go through seasons when I could not get out of the bed. I couldn’t do anything and I didn’t know what it was. And you know, because you don’t know what is wrong, people take it that you are lazy or you are un-motivated or you are un-focused.’ This meant that often employers would not keep her. ‘People would not understand, I would be late for work for say three, four, five weeks, and so they cannot handle it any more. They say “okay, we gave one warning letter, then the second warning letter, now we have to let you go because of lateness” or whatever the cause.’ Or she
would resign herself. ‘I would go through say six months being fairly well and I would start wearing down, and then I would have to resign. And because I didn’t know what was wrong, I had to give some flimsy reason why I am resigning from whatever job it is.
After the diagnosis there is no stability in symptoms. There are periods when she has so little energy, it is hard to even get
up. ‘Like today, actually the last say two weeks I have been unable to do even the most basic things like getting up, showering. I do not have enough physical energy to do a lot of things that would require me to get up, go to work, interact with people.’
The side-effects of medication also play a negative role. ‘I decided I wanted to see what it would be like not to be on medication because some of those drugs were making me basically completely spaced out. I couldn’t function at all, at all, at all. [They made me] drowsy like I think I slept through one particular seven-month period of my life.’ Given the instability of the illness, the periods of depression and not being able to
function properly, the limited record of job retention, it has not been possible to find or retain employment. She indicates: ‘I don’t know any employer who will be able to work with my ups and downs.’
This is the story of Bahati, a 23-year-old man who was
diagnosed with bipolar disorder about seven years ago. He narrates the impact of the illness on his work. ‘I started missing work, I started asking for time off. And I was the only person there at the Boutique, as well as the snack shop. I had to give out one; the snack shop I gave it out to my cousin, then I tried to work at the Boutique. But I still couldn’t.’
One of the reasons was the symptoms associated with the illness. ‘Then I [used] to move around a lot and talk a lot. And I couldn’t stay in one place and it was hard for me.’ His parents made him give up his job. ‘I never disclosed anything to [the owner]’ because ‘…he was also a family friend and my parents didn’t want word going out that I had a problem.’
The illness also affected him at school: ‘In my second year, the first semester I started going into maniac again, So when I stopped taking medication I think it affected me so I started missing school, I started missing classes, being late for classes.’ On account of it, he had to stop school: ‘So it reached a point now where the principal advise[d] that I take a break from school. Which I didn’t take very lightly because I felt that they didn’t understand me and my condition. But eventually my parents talked to me and I accepted to take the break. So I took the break – it was going for six months.’ He describes his experience at home and the lack of understanding: ‘“Why do you keep locking yourself in the room? Why can’t you go out like every other young guy? Why can’t you go make friends?” So they didn’t know. Sometimes I would just go and sleep excessively. […] They would take that as laziness and they would really lecture me a lot of times about that.’ He shares
not feeling supported by his father ‘I tell you, my dad has never […] been with me to a doctor’s appointment, apart from that one time at high school. At times, I would come home, just go to my room and cry a lot and sometimes even scream. And I am hitting things. My dad would be “Why are you crying? You are a man you need to be strong!”.’
Box 6.1: Case Studies 1 & 2 highlighting the experience of mental illness by two participants and the barriers
to employment
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you know. Some eat their own faeces and nobody cares. You know if they refuse to take medicine
they are beaten like cows. (PWMD4_Woman)
Similarly, in the questionnaire, mental illness was the highest reported limitation to opportunities
of employment (63.2%) (Table 6.2). An interviewee talks about how mental illness made her ill-
suited for formal employment because she was so tired of offering excuses to her employer about
her declining performance, then she opted to quit.
The illness was too much to cope with because there are those days when you don’t want to wake
up, there are those times you are in a bad mood, I just couldn’t manage. You know I was working in
the bank and the constraints are a bit high. My work was being affected and my performance kept
declining all the time and I felt I was doing my best, so I just thought if my best is not good enough,
I’d rather just let go. (PWMD8_Woman)
For another participant, again obtaining a job was not the problem but keeping the job was. In the
last year, she had resigned from four jobs and only later realized that her penchant for quitting jobs
was part of the peculiarities of bipolar disorder.
For me, getting jobs is quite easy but the problem is staying on the job. I really need, I want a job
and I want be employed. I actually quit my job on Friday… (PWMD9_Woman)
Social exclusion and stigma
The ignorance and myths surrounding mental disability accounted for the social exclusion and
stigma experienced by most of the study participants. They not only experienced stigma but also
anticipated stigma, which stopped them from completing education, seeking employment or having
intimate relationships. Their past experiences of exclusion made them feel they would always be
rejected or excluded. Describing their experience, one of the women in the FGD painted a vivid
picture of the ordeal of waiting in vain to be selected for work:
…We have been segregated. We cannot be selected for the job so I don’t go. Because why
should I stay one month sitting on a rock waiting for a job and I don’t get? I have wasted
my time. (FGD4_Women)
Table 6.2 shows that the fear of meeting people was among the self-reported limitations to
employment opportunities or having meaningful relationships. The social exclusion also meant
that they had reduced social networks and also treated unfairly by their family, community and
co-workers.
The treatment I have experienced from community is hate and rejection, stagnating and [hence]
no progress academically, professionally, socially. It was like I was somewhere in a cocoon or in an
enclosure somewhere. (FGD2_Mixed)
This experience also occurs in religious organizations where participants expected succour but
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Question Frequency (N) Percentage (%)
What factors limited your opportunities of employment/job? (N=40)
Employers do not want me 13 34.2
Due to my sickness 24 63.2
I am afraid of meeting people 9 23.7
I do not have useful employment skills 12 31.6
I do not have money to set up a business 17 44.7
Others 11 28.9
No response 4 10.0
In what ways can employers be of help to you? (N=72)
Allowing me sick leave 44 67.7
Ensuring other workers don’t discriminate against me 43 66.2
Allowing me to have flexible work schedules 37 56.9
Others 27 41.5
No response 7 9.7
What factors promoted your chances of employment? (N=32)
Supportive employer 6 27.3
Supportive family and friends 12 54.5
Disability movement/Support group 6 27.3
Self-motivation to work 4 18.2
Taking my medication 4 18.2
No response 10 31.3
What factors can promote your chances of employment? (N=72)
Informed and supportive employer 4 6.2
Self-employment and capital for business 17 26.2
Government support and welfare services 4 6.2
Job training and skills acquisition 14 21.5
Networking and participation in support groups 10 15.4
Not interested in employment 2 3.1
Others 14 21.5
No response 7 9.7
Table 6.2: Barriers to and facilitators of employment opportunities
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also lost positions on account of mental illness. According to one participant, her position in the
church was terminated after she disclosed her illness.
In fact, the most place that I experience stigma is at church. So I think, I think the church has failed
in terms of mental health. So there was a time I was chosen as a leader and when my name was
presented to the leaders, they said this lady is of unsound mind so I felt so bad. But I didn’t answer
them back although I sent somebody to go and tell them. So I stopped doing church activities. I
was teaching the church Sunday school. I stopped teaching in the church school. I just go now for
the meetings and I just go home. But I don’t take part in anything. (PWMD4_Woman)
The social exclusion and stigma led to the decision not to disclose even though they know that
disclosure would grant them the support they needed. Of the 14 persons involved in the interviews,
only six had disclosed their status to their present or past employers. The consensus opinion in the
FGD was that disclosure during an interview was bound to affect work opportunities because the
employer’s response may depend on his or her attitude to mental illness. For most of the study
participants, self-disclosure of mental illness was associated with negative reactions from society
and further isolation. Hence, most preferred not to disclose or share their problem.
…there is a problem in opening up and saying I suffer from mental illness because most people
think, it’s called madness. So you are stigmatized at work, you do anything that is a normal mistake
for anyone, but everyone goes like ‘no leave that one she’s got this problem’. (PWMD1_Woman)
Work identity crisis
Persons with mental illness are sometimes perceived as not fit or able to work. This myth is often
shared by persons with mental illness, leading to self-doubt in their perception of their ability
to work. The participants identified a work identity crisis as a limitation to opportunities for
employment. This was perceived as related to the self-doubt and reduced self-esteem that they
experienced on account of mental illness. While some of the participants identified the debilitating
nature of the illness as the problem, others suggested that it was a result of the social exclusion
they experienced that forced them to believe that they are unable to work. A participant in the
FGD with USP described his experience: ‘There were jobs I refused to go because I was afraid. I recall
they could invite me and I could not even engage myself. Yeah others I could leave halfway and there are
others I could do very incompetently that they would not want to see me back… (FGD2_Mixed).
Similarly, a participant in interview narrated her inner wish that she would not be employed and
her belief she is not capable of work.
I was going for an interview, but deep down in my heart I was like, I hope I am not chosen because if
I am chosen and I go for an interview and I don’t do well my world would be shattered. (PWMD1_
Woman)
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Non-accommodative environment
Also related to social exclusion and stigma is the non-accommodative nature of the socio-political
environment. Although persons with other disabilities were sometimes recognized and assisted
in society, this was different for persons with mental disabilities. The misconception of and
biases regarding mental illness thus constitute a barrier to education, health and employment.
The majority of the participants had their education interrupted by mental illness and were not
extended the accommodation they deserve in the same way as other persons with disabilities.
There is discrimination, because ... just the way they make sure that there are ramps for people
with wheelchairs to walk on, they should also provide ways in which somebody with a mental
illness is able to cope at their level. And then also with the medication… (PWMD8_Woman)
This same attitude was found in the health sector where they faced challenges from insurance
companies that refused to allow them to take out an policy and healthcare providers that treated
them unfairly. Regarding the insurance companies, a participant in the FGD declared: ‘So, I think
there is a problem at the policy level and the treatment level and also the insurance companies are also
very discriminatory but accommodating for other diseases…’ (FGD2_Mixed). Narrating her ordeal in a
public hospital one participant stated:
One time, I was so depressed, I was like so suicidal and I just wanted like to get back on my
medicines. So I went there at around 4.30 and they told me that the doctor cannot see anyone
else because she is supposed to – uhm –normally it is supposed to open from 8 to 5, so, this is at
4:30 and they are telling me that I cannot see the doctor because I came in late. That was like a
huge blow. (PWMD9_Woman)
In the workplace, the study participants recounted stories of termination on the disclosure of
their illness. This non-accommodative work environment was perceived to be worse in private
organizations than in public or government-owned organizations where the bureaucracy
sometimes protected them from being sacked.
In my experience, it is better to work in public rather than private. In the private sector, if you make
a mistake, they sack you immediately; there is no process but sacking somebody in the public
sector is quite a process. (PWMD4_Woman)
The negative attitude of employers was reported by 31.6% of study participants as the major
limitation to their being employed (Table 6.2).
Socioeconomic status
The study participants identified socioeconomic status as a major determinant of their experience
of mental illness. This was because it determined if they were able to buy their medications or
access hospital care, by food, complete their education amidst the interruptions, or harness self-
employment as an alternative to employment. These feelings of helplessness were described by a
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participant in the FGD with members of USP.
Actually now here it depends on the social strata or the economic status of an individual. There are
those people who can afford to seek the private health services. But there are very many people
who don’t have the choice, of where to go so they are just ushered in to the [National Referral
Psychiatric] Hospital. (FGD2_Mixed)
The financial challenges faced by participants of low socioeconomic status was so enormous that
they were unable to buy medications even when they wanted to. One participant described the
choices some of her friends had to make to buy food rather than spend the money on medications,
because the hunger for food was greater than that for medication.
…I have worked with people from lower socioeconomic status and I have seen when they have to
decide between medication and food …which is it either or you know yeah. So that sort of choice I
never had to make … knowing that I will wake up and there would be sort of food waiting and being
able to go to the hospital and keep getting more medications. So, I would say that also helped in a
way just …that sort of social economic status. I would say helped in a way. (PWMD13_Woman)
This dire financial challenge was also noted in the responses of participants who completed the
questionnaire. The lack of money to set up a business was the second-highest reported limitation
to opportunities of employment (44.7%) (Table 6.2). The lack of access to capital was summed up
by a participant in the FGD: ‘most of the people here have skills. They are very skilled; but getting capital
is the problem’ (FGD1_Mixed).
Factors hampering employment are closely intertwined, and when analysed through the individual
versus environmental lens, we see perpetuating effects of both. Looking at the inseparability of
individual and environmental factors, it would be hard to argue that responsibility for facilitating
employment of people with a mental disability lies solely with society, or solely with the individual.
While stigma plays a part in exclusion from education, or health care (which in turn leads to
sustained symptoms), it also leads to anticipated stigma and self-stigma, which prevents people
from finishing education or looking for employment. Hence, there is no single, unequivocal starting
point for improving the employability and employment of people with a mental illness. Just like the
different pathways through the individual–environmental nexus that lead to low employment of
people with a mental disability, different pathways may be identified that may facilitate employment.
Factors that facilitated or may facilitate employment opportunities
Once more, using the case studies discussed previously, we highlight the factors that facilitated the
employment experience of the individuals (Box 6.2). Subsequently, we discuss the major themes
that facilitated or may facilitate employment based on the experience of the study participants.
In spite of the challenges faced by Nyawira and Bahati, they managed to find different pathways
to fulfil their needs for employment. For Nyawira, her knowledge of finance, education and family
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support made it possible to engage in self-employment. For Bahati, finding an employer who
was willing to offer him reasonable accommodation saved the day. It is pertinent to note that his
disclosure to his boss was not spontaneous. He stated: ‘now there came this day I broke down at
work, so that’s when I had to tell my boss, actually I had to apologize for not telling them, because after
all they were like, I was in their hands when I am working there. If anything happens to me they would be
held accountable’. His experience also highlights the unpredictability of an employer’s reaction to
disclosure and that it is not always negative. It is pertinent to note that both Bahati and Nyawira
share the importance of self-awareness; it was after understanding their illness and accepting that
it was there to stay that they learned to deal with the symptoms and found the strength to push
themselves further.
Other study participants also shared their experiences of factors that facilitated employment
or improved employment opportunities. These factors include self-awareness and acceptance,
self-employment, provision of reasonable accommodation, improved health services, addressing
discriminatory laws and practices and social development programmes and support. We observed that
Box 2: Case Studies 1 & 2 highlighting factors that facilitated employment
Case Study 1 Case Study 2
Nyawira solved her employment challenges by embracing self-employment. She now runs a small business selling
beauty products and is planning on starting a school bus company. She stated that: ‘Once I understood what was wrong with me and what needed to work, I mean how I needed to figure, I mean what I needed to figure out in order to be financially stable, I started a business. So I run a small business I sell beauty products and the reason why it works for me is because I do deliveries.’ What helped her in this transition was: ‘I understand a lot of financial instruments, so one of the things that once I accepted my diagnosis, I figured out OK, so clearly the workplace will never really work for me…I actually have to be disciplined enough to put aside money, the second thing was access to credit which I think was one of the biggest hurdles for me and I knew I was not creditworthy with the bank because I don’t have a job and my business is not big enough for them. So I started, I looked for a SACCO I could join, and I found one and I joined and after I think about a year and two months, I was able to take my first loan and I bought a car for the business’.
In addition to her knowledge of finance, she avers that self-awareness and motivation also helped her in her journey to
self-employment: ‘once you are brutally honest with yourself then what happens is you are able to do your best, you are able to push yourself as far as you can’. Also, the support from her family helped her cope with her illness and engage in self-
employment: ‘I have a very supportive husband and he sometimes does my deliveries for me’.
Family and social support was also related to education and
social status: ‘Because for me the fact that the people around me are probably on the same socioeconomic level, means that they, they have a much better understanding of the mental illness and so they are able even if they don’t understand it completely, they are able to give me more, a leeway to work around my limitations’.
Bahati found employment with an accommodating employer: ‘Then I told them that I am actually bipolar…that’s when he also told me that he also had a reading disorder. So he explained to me how for him it was for him, how he worked with it and the challenges he faced in school and how he even came to start working’. He also describes the provisions his boss made for
him: ‘They are paying for my whole entire fees. They are paying for my projects and also they gave me a job. So they told me after, when I finish school, I have a job there. So it was, for me it was positive because I, I felt like, I felt somehow inadequate while working there cause I didn’t feel I was good enough’.
Joining a support group changed things for him: ‘So being there really helped me. You see with my friends I can’t tell them how I feel, I can’t tell them how I am at certain period. Because it’s hard for them to tolerate what I am actually going through, because none of them have what I have and they can only do so little. But with someone who actually has the same if not a similar condition as you are it’s a very different way. Because if you talk with them they actually understand’.
He reflects on the usefulness of self-awareness and motivation: ‘Then I realized that very few people would care whether I am sick or not. You have to deliver. If I have employed you, you have to deliver whether you are sick or not. I know you are sick but you cannot keep on asking for time off and yet you are getting paid. It’s your job, you either work hard on it or you are going to lose it. And getting another one is a big problem, it’s a big challenge. Especially someone fresh from School, it’s a big challenge. So for me whether I was sick or not I used to go to work and I used to work. And I used to make sure that I deliver. So I knew I had something slowing me down, I knew I had a challenge with my health. But regardless of that I made sure that I do my best, I do my best’.
Box 6.2: Case Studies 1 & 2 highlighting factors that facilitated employment
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self-awareness and acceptance of illness were very relevant to recovery, coping and the decision
to work.
Self-awareness and acceptance
Study participants spoke of self-awareness and acceptance of the illness as a major turning point in
their lives and also in the bid to secure employment. They suggested that personal understanding
of their illness motivated them to overcome the burden of illness opt for employment. One
participant recounted how self-acceptance helped him to move on: ‘I came to the understanding that
this is how I am and probably I might be like this for the rest of my life so I rather to come to terms with
it or and deal with it or continue suffering’ (PWMD5_Man). This view was also echoed by another
participant who stated:
...the first things is that you accept yourself; in fact it is the most important thing because when
you accept that you have a challenge, you have a mental illness, you will know that you may never
leave medications. Sometimes you have to make painful decisions which will cost you dearly. The
world would not understand you, the people around you do not have the knowledge that you have
about you. (PWMD7_Man)
Although qualitative data suggests that self-awareness and acceptance are key to self-motivation,
only 18.2% of the participants in the survey who were employed identified self-motivation as one
of the factors that promoted either employment or self-employment (Table 6.2).
Self-employment
Like Nyawira, many study participants considered self-employment as flexible and viable to escape
the challenges of the formal work environment and fluctuating pattern of mental illness. The
relevance of self-employment in the employability of persons with mental disability was reported
by most study participants. Self-employment was conceived as an alternative to formal employment
which they were unable to secure or is difficult for them to endure owing to the challenges specific
to their illness. Participants recounted how they gave up formal employment for self-employment
because it offered them more peace of mind.
...so I left my job and decided not to seek employment. Even when I have a job, getting to work is
not all that easy. So, I chose to be in self-employment so that I can sleep all I like and I don’t have
that pressure of time. (PWMD11_Woman)
Of the 14 interviewees, five were self-employed and four spoke of their intention to give up their
formal employment for self-employment. Self-employment and capital to set up business was the
highest reported facilitator of chances of employment among study participants who completed
the questionnaire (Table 6.2). On self-employment, one participant declared: ‘Then about the self-
employment I think that’s perfect work for people like us. It’s more flexible’ (FGD1_Mixed).
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Provision of reasonable accommodation
Self-employment is not an option for everybody, and even for persons without disabilities it may
be challenging. As employment is a human right, both the government and employers have a duty
to provide reasonable accommodation to facilitate employment for persons with disabilities. The
provision of reasonable accommodation was, indeed, identified as a facilitator of employment and
includes education, employment and healthcare services. Given the fluctuating nature of mental
illness, participants suggested that policies that ensure reasonable accommodation in education
would assist them acquire an education in spite of their illness. One participant recounted the
accommodation provided by his school to enable him to continue his education despite the
challenges of his illness.
...and it’s good that the school has been very cooperative, I mean they understand my situation.
So, they gave me the break for two weeks. I just took a rest was able to complete my projects
during that time…. (PWMD5_Man)
Among those who were employed, reasonable accommodation in the workplace in the form of a
supportive employer amounted to what ensured employment. According to one participant:
…working in a big and supportive company that provided medical cover helped. There was a time
when admission was the order of the day so if that was not provided then it would have been
difficult for me to access care… (PWMD8_Woman)
Asked how employers may be of help to them, allowance of sick leave (67.7%) and ensuring that
other workers do not discriminate against them (66.2 %) were the needs most reported by the
participants who completed the questionnaire.
In order to improve employability, there needs to be reasonable accommodation (e.g. allowing for
sick leave in education and employment). Similarly, the participants suggested that owing to the
overwhelming nature of their illness and nature of healthcare services, policy-level interventions
that would ensure the right to health would improve both access to and uptake of health care,
which would strengthen their workability.
Improved healthcare services
The pivotal nature of the health system in facilitating employment was reported by most of the
study participants. They suggested that having affordable and appropriate medications and mental
health care could make a difference. Among those who were working, compliance with medications
and their availability were suggested as very important to their workability. When asked about the
most important factor that helped workability, one participant stated: ‘I think the first is just getting
treatment, …not just treatment but getting the treatment that works for you … I think treatment should be
made much, much cheaper’ (PWMD10_Woman).
They also suggested that the availability of the effective medications in the public hospitals would
Employability of persons with mental disability
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make it possible for them to obtain them. One participant narrated her experience with cheap
medications:
… So, I went back to the cheap drug, that one only costed me two shillings…but you see it’s not
having very nice side-effects. But when I relapsed in 2014, actually the reason why I relapsed
is because I was so fed up with that medication, the cheap drug. You know it was hurting me
mentally and physically. There were so many things I couldn’t do. You know I am a writer, I couldn’t
write, I couldn’t write. (PWMD11_Woman)
Among those who were employed, taking their medications (18.2%) was identified as one of the
enabling factors for employment (Table 2).
Addressing discriminatory laws and practices
The participants suggested that addressing the discriminatory laws and practices which are rife
in the country would ensure inclusive employment practices. Participants stated that as long as
the laws were discriminatory and used stigmatizing language such as unsound mind, it would be
difficult for employers to consider them for employment. This was aptly captured by a participant
who retorted: ‘Who is going to employ you if they believe you have mental illness because you use
drugs or are crazy?’ (PWMD12_Woman). This statement also captured one of the challenging
misconceptions that every mental illness was related to drug use. Participants suggested that the
non-implementation of policies on inclusive employment was a barrier to their employment. One
such discriminatory practice was the red tape surrounding the acquisition of a disability certificate,
which is so much more difficult for persons with mental illness compared to persons with other
disabilities.
...getting the disability card has some benefits for persons with disability. But completing the
medical assessment takes up to six months for person with mental disability. Reducing this time
would encourage people to go for the card and help them in the search for job… (PWMD14_
Woman)
Participants recommended better mental healthcare services in public hospitals and identified the
role of the government in ensuring equitable care.
The government can also put some regulations in public hospitals so that there are services for
the mentally disabled so that they can be treated and can get jobs without being looked at as
less able or incompetent simply because they have not gotten the services from the hospitals.
(FGD3_Men)
The overall improvement in attitudes to mental illness through information was deemed as relevant
to improved employment for persons with mental disabilities. This was noted as critical to a change
in discriminatory policies and practices. One participant stated: ‘The government is the one that
needs to set the ball rolling in terms implementation… we have the policy but we need the implementation
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and follow-up. People need to be educated and informed about mental illness…’ (PWMD13_Woman).
Social development programme and support
The participants identified social development and support as useful for improved employment
opportunities for persons with mental disabilities. Most decried the lack of government social
welfare provisions, and how these would address the inequity they face because of mental
disability. Government support and welfare services were among the factors participants said
might improve their chances of employment.
So I think the government is the one who could help….Because if they put legislation can help you
when you are sick or just create opportunities for employment and they can also ensure people are
accommodated and get equal opportunity in employment. (PWMD11_Woman)
Participants also identified the provision of welfare services by the government helpful for
employment or self-employment. Similarly, participants in the questionnaire survey suggested that
provision of job training and skills acquisition (21.5%) would facilitate employment opportunities
(Table 6.2).
Social support from families, friends and mental health support groups was described as invaluable
to employment. Among those who were employed, supportive family and friends was the highest-
reported enabler of employment (54.5%) (Table 6.2). According to one participant, without the
support of his family, he would not have completed education or be employed: ‘My family helped
me…OK even my mum always asks me if I have taken my medication. They are supportive, you know
family is your family. Your brother will be your permanent friend. Your sister will also be your sister.’
(PWMD6_Man)
Also, participants identified networking with support groups as one of the facilitators of
employment and coping with mental illness. One participant stated: ‘USP Kenya has helped me,
because I got a crowd where I know it is not only me. Because when you are alone you only think it is only
you. You know I thought, I came to know it is not only me, it is a disease that many people have. And people
do work, and people are educated (PWMD4_Woman).
To conclude, factors relevant for improving the situation are not solely dependent on the individual
or the environment but are interrelated. In spite of self-awareness and a personal decision to
work, it would still be difficult to function in settings where an individual is denied basic health
care, reasonable accommodation in the workplace or where cultural beliefs and attitudes to
mental illness deprive individuals of their fundamental human rights to social benefits and a social
network. Conversely, if environmental factors are in place and individuals do not wish to work
because of anticipated discrimination or self-doubt, employment rates would remain low.
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6.4 Discussion
In this study, we set out to explore the lived experiences of persons with mental disabilities such
as Nyawira and Bahati, and how they have managed against all the odds to secure and stay in
employment. In order to achieve our study objectives, we identified several complex and limiting
experiences which were conceived as barriers both to daily activities and to employment. In
addition, the study participants who were employed identified the factors that facilitated their
opportunities of employment; all study participants suggested perceived facilitators of employment
opportunities. It is pertinent to state that the complex interaction of individual and environmental
factors was conceptualized as both a barrier to and facilitator of employment.
Our study showed that mental illness was the highest self-reported barrier to employment
opportunities. This perception was related to the debilitating nature of the illness experienced, the
side-effects of medications, its propensity to deprive affected individuals of education needed for
employment and the reduction of their social network. Our findings in Kenya add to the established
relationship between psychiatric illness and unemployment and the capacity of the illness to be a
direct limitation to work [19, 36, 39, 40]. It is pertinent to state that our observation from the
field and the stories from the qualitative study also showed that the effect of mental illness on
the individual may be independent of the severity of the illness. We had respondents with anxiety
disorder who cannot hold a job because the sound of the office phone makes them jumpy. We also
met persons with schizophrenia who were successfully employed and even owned houses of their
own.
We noted heightened reports of social exclusion and stigma experienced in education, thus denying
the persons with mental illness of the education that they need for employment. The stigma also
affected them in their experience of health care, since maltreatment was prevalent in the few
mental health hospitals in the country. Lastly, social exclusion also occurred among employers and
co-workers, making them give up work in formal settings on account of anticipated stigma. These
findings are corroborated by studies in high-income countries but what makes our study different
is the absence of mechanisms in our setting to ensure reasonable accommodation for persons with
mental disabilities [30, 41-43]. The absence of these mechanisms also highlights the heightened
effect of these experiences on work opportunities. Despite legislation, few civil mechanisms are
in place to ensure that affected individuals receive redress unless they approach the courts [5],
which may be even harder for individuals without the means to buy food or medication. These
observations underline the impact of socioeconomic status on the overall experience of mental
disability, which the study participants also identified as a limitation to employment opportunities.
Studies agree on the impact of poverty on disability and its role in worsening the experience of
mental illness [1, 6, 44, 45].
Our study is replete with stories that point to a work identity crisis and the feeling of reduced
self-worth. Studies have linked this to anticipated discrimination and hence the recommendation
by Thornicroft and colleagues for addressing self-esteem in stigma-reduction interventions [41].
However, it may be worthwhile to also consider it as a feature of the psychiatric illness or an
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individual’s personal decision not to work. Self-motivation was reported as one of the facilitators of
employment by the study participants who are employed. Some of our study participants indicated
they were not interested in working and this line of thought is supported by a recent study that
suggests that not all persons with disabilities desire to work and should not be pressured to do
so [46]. Although this seems to support the need for classification of personal factors (as possible
barriers and enablers) in the International Classification of Functioning, Disability and Health
(ICF) as suggested by Escorpizo and colleagues [47], it may also lead to governments shirking of
their responsibility. Nevertheless, Mulvany (2000) recommends acknowledging that individuals
differ and persons with mental disabilities may also differ in their desire for work [10]. What we
may be unable to confirm is whether the (reduced) desire for work is due to the illness or part
of its symptomatology. Our study does suggest that social and health systems that support the
individual on their journey to acceptance are greatly needed.
Our study suggests that persons with mental disabilities can work if they receive support at home,
school, hospitals, the workplace and indeed in all spheres of life. Having a supportive family and
friends was the highest reported facilitator of employment among those who were employed.
This finding, which is supported by studies on the importance of social networks and capital for
persons with mental illness, portends good news [48-50]. It shows that harnessing support in
immediate families and community may improve the employment experience of persons with
mental disabilities. It is related to the provision of reasonable accommodation in the workplace
and healthcare sectors which our participants suggested as facilitators of work opportunities.
Evidence of the importance of reasonable accommodation in both employment and a return to
work schemes have been documented [17, 51, 52]. The pivotal nature of improved health services
through provision of universal health coverage and non-discriminatory insurance schemes cannot
be over-emphasized. The provision of friendly and non-discriminatory health services, and
functional procurement of essential medicines would go a long way in reducing the side-effects
arising from using cheap and out-of-date antipsychotics with a broad spectrum of side-effects [53].
This is in line with the recommendations of the Convention on the Rights of person with disabilities
(CRPD) and the SDGs to ensure equitable health care for person with disabilities [2, 22].
The role of government in all these areas is highlighted in the suggestions made by study
participants on the need to address discriminatory laws and practices and to provide development
programmes. Affirmative action is essential because, as the participants noted, there are laws
in Kenya but an absence of political will to implement them, including social welfare for persons
with disabilities [9]. This policy–practice gap affects work opportunities for persons with mental
disability. The existence of discrimination in identifying mental illness as a disability and easing
the process for acquiring a disability card in Kenya would ensure that affected individuals receive
the reasonable accommodation they deserve. A study in South Africa has also documented the
challenges in accessing the disability certificate for persons with psychiatric disabilities [54].
Participants in the study suggest the need for social development programmes to enable them
to acquire skills and engage in self-employment. The establishment of social development
programmes would also provide individuals who want to opt for self-employment to be helped in
Employability of persons with mental disability
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6
their efforts to set up economic activities. The importance of self-employment for persons with
disabilities has been previously documented [18, 21] – hence the promotion of village savings and
loans as a means of capital generation and economic empowerment for persons with disabilities by
the Cristian Blind Mission [55]. Ostrow and colleagues suggest that self-employment for persons
with psychiatric disabilities has advantages such as self-care, choice of career and additional
earnings; but they also noted that it is fraught with challenges and sometimes difficult to sustain
especially where stigma and lack of social support exist [18]. There is need for the government to
support community-based rehabilitation (CBR) programmes for persons with mental disabilities
in Kenya to engage in self-employment and entrepreneurship in line with Article 27 of the CRPD
[22].
Our study is one of the first in Kenya that has set out to explore the employment challenges
of persons with mental disabilities. The strength of our study lies in using the case-study
approach and the involvement of the study participants in the study and analysis. Thus, it
ensured that the voices and messages of the participants took precedence over the yearnings
of researchers. Also, the exploration of our study question through qualitative and quantitative
means ensured a validation of our study findings. However, these findings are not generalizable
on account of our limited sample size. It is also pertinent to state that participants’ stories may
have been affected by recall bias or social desirability. In addition, our findings reflects the
perspectives of the study participants and may have missed the views of non-participants.
6.5 Conclusion
Our study has highlighted that persons with mental disabilities in Kenya can work. It has laid to rest
the belief of employers and certain social segments that they cannot work. We have also shed light
on the various challenges (personal and environmental) affected persons encounter in their quest
to enjoy their fundamental human right to employment. The problems are many but they are not
impossible to overcome. Our study holds promises of improvement if they receive support from their
social networks. The fulfilment of government obligations is pivotal to the enjoyment of reasonable
education, health care and employment for persons with mental disabilities in Kenya.
Conflict of interest
The authors declare no conflict of interest.
Author contributions
IDE, BJR, and JFGB-A were involved in the research design. IDE collected the data and analyzed
it with MG, EO, JFGB-A, and BJR. IDE wrote the initial draft, which was revised by MG, EO,
JFGB-A, and BJR. All authors approved the final version of the manuscript for submission.
Acknowledgement
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium FPA 2013-0039 (SGA2016-1346).
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The authors are grateful Michael Njenga and all the study participants from Users and Survivors
of Psychiatry, Kenya and African Mental Health Foundation. Mònica Guxens is funded by a Miguel
Servet fellowship (MS13/00054, CP18/00018) awarded by the Spanish Institute of Health Carlos
III (Ministry of Economy and Competitiveness). ISGlobal is a member of the CERCA Programme,
Generalitat de Catalunya.
Employability of persons with mental disability
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Published asEbuenyi ID, Regeer BJ, Ndetei DM, Bunders-Aelen JF, Guxens M. Experienced and anticipated
discrimination and social functioning in persons with mental disabilities in Kenya: implications for
employment. Frontiers in Psychiatry. 2019;10:181.
C H A P T E R 7 EXPERIENCED AND ANTICIPATED
DISCRIMINATION AND SOCIAL
FUNCTIONING IN PERSONS WITH
MENTAL DISABILITIES IN KENYA:
IMPLICATIONS FOR EMPLOYMENT
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CHAPTER 7: EXPERIENCED AND ANTICIPATED DISCRIMINATION AND SOCIAL FUNCTIONING IN PERSONS WITH MENTAL DISABILITIES IN KENYA: IMPLICATIONS FOR EMPLOYMENTAbstract
Introduction: Persons with mental illness experience social life restriction and stigma that may
have implications for their work ability. The aims of this study are i) to report experienced and
anticipated discrimination and social functioning in persons with mental disabilities in Kenya
and ii) to investigate the association between experienced and anticipated discrimination, social
functioning, and employment in this population.
Materials and Methods: Cross-sectional study design where we randomly recruited 72 persons
with mental illness through two networks of persons with psychosocial disabilities in Kenya.
Experienced and anticipated discrimination were measured using the Discrimination and Stigma
Scale version 12 (DISC 12) while social functioning was measured using the Social Functioning
questionnaire (SFQ).
Results: Experienced discrimination was reported by 81.9% in making or keeping friends, 69.7%
and 56.3% in finding or keeping job respectively, and 63.3% in dating or having an intimate
relationship. Anticipated discrimination stopped 59.2% from applying for work, 40.8% from
applying for education or training courses, and 63.4% from having a close personal relationship.
Females reported an overall higher experienced discrimination than males. Unemployed
participants had slightly increased rates of experienced and anticipated discrimination (9.5 vs. 9.1
and 2.5 vs. 2.3, respectively) (p>0.05), while there was a significant association between impaired
social functioning and unemployment (14.0 vs. 11.2 (p=0.037)).
Conclusion: The rates of experienced and anticipated discrimination faced by persons with mental
disabilities in Kenya is high and with significant gender disparity. Although no strong associations
were observed between experienced and anticipated discrimination and employment, impaired
social functioning of persons with mental disabilities seems to have implications for employment.
Further research is essential to understand the predictors of the discrimination and measures to
reduce them in persons with psychosocial disabilities.
Key words: mental disability, discrimination, social function, employment, Kenya
Discrimination, mental disabilities, and employment
123
7
7.1 Introduction
Globally, mental illness is among the leading causes of disability and social exclusion [1]. Persons
with mental illness experience social life restriction and stigma that may have implications for
their work ability [2, 3]. While it is often challenging to untangle the causal links between social
functioning, stigma, and the occupational life of persons with mental illness, studies demonstrated
that persons with mental illness have increased rates of stigma, impaired social functioning, and
unemployment compared to the general population [2-5]. These disadvantages have implications
for their social participation and human rights. Addressing this imbalance is important but it is still
a neglected societal issue especially in low income countries with paucity of research on mental
illness [6, 7].
Studies in high income countries have demonstrated that stigma for mental illness is manifested
through both overt and covert actions that result in discrimination against persons with mental
illness [8, 9]. These systematic societal attitudes isolate persons with mental illness and produce
social disadvantages in major areas of life such as work and school. Experienced discrimination is as
a result of perceived unfair treatment while anticipated discrimination occurs when an individual
limits his or her activities on account of fear of discrimination [10] . A mixed method study by
Thornicroft and colleagues that analyzed data from 27 countries revealed that experienced and
anticipated discrimination affected the work, education, and social life of persons with mental
illness [3]. A more recent cross sectional study in the UK that explored coping mechanisms in
mental health service users showed that illness concealment as a coping mechanism found in
73% of participants was associated with anticipated discrimination [11]. This finding is consistent
with a similar study in Australia that reported a 50% rate of both experienced and anticipated
discrimination in participants with severe mental illness [12]. In Nigeria, a study by Oshodi et
al reported that experienced and anticipated discrimination in young people affected their
social interactions and work ability [13]. Furthermore, studies indicated a gendered pattern to
discrimination, with women having higher rates of anticipated discrimination than men [14, 15].
Finally, impaired social functioning has also been associated with a lower employability among
individuals with mental illness mainly in high income countries [4, 16, 17].
In spite of the abundance of studies linking stigma, impaired social function, and employment in
persons with mental disability, few exist in Africa [18] . While the evidence in high income countries
is growing, it is essential to replicate such studies in low income countries where there is heightened
stigma for mental illness. These studies would provide information on the magnitude of the problem
in such regions and serve as evidence with which to engage policy makers on the need for the
establishment of change processes to mitigate the challenges persons with mental disability face.
Therefore, the aims of this study are i) to report experienced and anticipated discrimination and
social functioning in persons with mental disabilities in Kenya and ii) to investigate the association
between experienced and anticipated discrimination, social functioning, and employment in this
population.
CHAPTER 7
124
7.2 Materials and Methods
Study design and population
A cross-sectional study design was employed, where we randomly recruited persons with mental
illness through two networks of persons with psychosocial disabilities: Users and survivors of
psychiatry (USP) and African Mental Health Foundation (AMHF) in Kenya. The target population
was living in Nairobi county and the surrounding rural settlements. A total of 120 persons were
invited, and 72 (60%) accepted to participate in the study. Participants answered a researcher
designed questionnaire in English or Swahili language, the official languages in Kenya.
Experienced and Anticipated Discrimination
We used the Discrimination and Stigma Scale version 12 (DISC-12), a 34 item interview-based
and standardized tool for assessment of discrimination that has been used in both high income
countries and low-and-middle-income countries [3, 10]. The DISC-12 has good psychometric
properties including inter-rater reliability (weighted kappa range: 0.62-0.95), internal consistency
(α=0.78) and test-retest reliability (weighted kappa range: 0.56-0.89) [10]. It consists of a global
scale and four subscales: (1) Unfair treatment (item 1-22); (2) Stopping self (item 23-26); (3)
Overcoming stigma (item 27-28), and (4) Positive treatment (item 29-34). The unfair treatment
subscale assesses unjust treatment by other people and higher scores indicate greater experienced
discrimination. The stopping self-subscale explores the extent to which an individual limits his/her
activities of daily living (e.g. work) due to fear of stigma and higher scores mean higher anticipated
discrimination. The overcoming stigma subscale measures an individual’s ability to overcome stigma
and higher scores indicate a higher ability to cope with discrimination. The positive treatment
subscale assesses positive treatment received by an individual on account of mental illness and
higher scores mean greater positive treatment received by the individual. The responses to the
DISC-12 are rated on a four point Likert scale (Not at all=0, A little=1, Moderately=2, and A lot=3).
The mean for the overall and subscales scores were calculated by summation of the rating (0-3) for
each item and dividing with the total number of applicable terms. The count for the total score for
the overall and each subscale were calculated by counting the number of items that the individual
scored as 1 (a little), 2 (moderately) or 3 (a lot) [19]. The higher the scores, the greater the stigma.
Social functioning
We used the Social Functioning Questionnaire (SFQ), an eight-item self-reported scale (score range
0–24) that provides a quick assessment of perceived social functioning. It was developed from the
Social Functioning Schedule (SFS) and has good test-retest and inter-rater reliability, including
construct validity [20, 21]. The SFQ are sets of questions that cover diverse life domains such as
work, home, relationship, financial problems, sexual life, and relationship (Supplementary Table
7.1). The responses are on a four point non-uniform scale. A score of 10 or more indicates impaired
social functioning [21]. We categorized the scale as high (score below 10) and low (score of 10 or
above) social functioning.
Discrimination, mental disabilities, and employment
125
7
Sociodemographic characteristics and employment
We obtained information on age, gender, educational level, marital status, number of children, type
of mental disability diagnosed, employment status, job satisfaction (among the employed), interest
to be employed, and belief on how employment can have an impact on their medical recovery
through a self-reported questionnaire.
Data management and statistical analysis
Descriptive statistics were used to examine the relationship between sociodemographic
characteristics and employability by means of means and standard deviations for continuous
variables and proportions for categorical variables. Independent samples t-test, One way analysis
of variance (ANOVA) and Chi-square/Fischer’s exact test were used to identify group differences
between the employed and unemployed depending on the distribution of the independent
variables. All analyses were conducted using IBM SPSS version 23 (IBM, New York USA).
Ethics
The study design was approved by the Amsterdam Public Health science committee (WC2017-
011). The Maseno University Ethics Review committee approved the study (MSU/DRPI/
MUERC/00391/17). Maseno University Ethics Review Committee (MUERC) is the Institutional
Review Board (IRB) of Maseno University and has a mandate from the National Commission for
Science, Technology and Innovation (NACOSTI) Kenya to grant review and grant approvals for
research in Kenya. Informed consent was obtained from all study participants. 7.3 Results
Participants characteristics
Socio-demographic characteristics of the participants are shown in Table 7.1. Out of the 72
participants, 69.4% were females and most of them were unmarried (70.8%). In terms of the self-
reported mental illness typology, 31.3% indicated having depression, 29.7% depression together
with other comorbid conditions, 20.3% bipolar disorder, and 18.8% schizophrenia and other
psychotic conditions. Slightly more than half (55.6%) were unemployed and of those that were
employed, half were self-employed and 46.9% were satisfied with their jobs. Overall, a total of
76.8% were interested to be employed. Experienced and anticipated discrimination
Mean score for experienced discrimination (unfair treatment subscale) was 0.9 (SD=0.5) and
for anticipated discrimination subscale (stopping self-subscale) was 1.4 (SD=0.9) (Table 7.2).
Experienced discrimination (unfair treatment subscale) was reported by 81.9% in making or
keeping friends, 69.7% and 56.3% in finding or keeping a job respectively, and 63.3% in dating or
having an intimate relationship (Figure 7.1, Supplementary Table 7.2). Anticipated discrimination
(stopping self-subscale) stopped 59.2% from applying for work, 40.8% from applying for education
or training courses, and 63.4% from having a close personal relationship.
Females reported significantly higher experienced discrimination (unfair treatment subscale)
CHAPTER 7
126
in finding and keeping a job, in housing, and in their personal safety and security while men
experienced more discrimination in being shunned or avoided by people who know that they have
a mental health problem, in their education, and by the police (Table 7.3, Supplementary Figure
7.1).
When comparing the distribution of the socio-demographic characteristics across the
discrimination subscales, females had a higher mean score of overall experienced discrimination
(unfair treatment subscale) as compared to males (10.0 vs. 7.7) (Table 7.4). Those diagnosed with
Table 1. Socio-demographic characteristics of the participants (N=72)
Variable Categories Distribution N (%)
Age 30 years and below 10 (13.9)
31-40 years 29 (40.3)
41 years and above 33 (45.8)
Gender Male 22 (30.6)
Female 50 (69.4)
Marital status Unmarried 51 (70.8)
Married 21 (29.2)
Number of children None 16 (23.5)
With children 52 (76.5)
Missing 4
Education level Primary and below 32 (45.1)
Secondary and above 39 (54.9)
Missing 1
Type of mental disability diagnosed
Schizophrenia and other psychotic disorders 12 (18.8)
Depression only 20 (31.3)
Depression and other comorbid conditions 19 (29.7)
Bipolar disorder 13 (20.3)
Missing 8
Employment status Unemployed 40 (55.6)
Employed* 32 (44.4)
Job satisfaction (among the employed)
Satisfied 15 (46.9)
Not satisfied 17 (53.1)
Interested to be employed Yes 53 (76.8)
No 16 (23.2)
Missing 3
*15 out of the 32 employed participants were self-employed.
Table 7.1: Socio-demographic characteristics of the participants (N=72)
Discrimination, mental disabilities, and employment
127
7
Table 2. Stigma and Social Function Scores
Mean (SD) Min-Max.
DISC total mean a 1.3 (0.4) 0.4-2.2
Unfair treatment 0.9 (0.5) 0-2
Stopping self 1.4 (0.9) 0-3
Overcoming stigma 1.9 (1.1) 0-3
Positive treatment 0.9 (0.8) 0-3
DISC total count b 14.8 (5.4) 0-29
Unfair treatment 9.3 (4.4) 0-18
Stopping self 2.4 (1.2) 0-4
Overcoming stigma 1.5 (0.7) 0-2
Positive treatment 2.4 (2.0) 0-6
Impaired social functioning 12.8 (5.7) 3-23
Social functioning levels High (33.3%) Low (66.7%)
b DISC Total Count is the count of the number of items endorsed in the aDISC total scale or subscales; DISC Total Mean is the mean DISC total scale or a subscale score
Table 7.2: Stigma and Social Function Scores
Figure 7.1: Proportion of agree responses for DISC item. UT=Unfair treatment subscale; SS=Stopping self-
subscale; OS=Overcoming stigma subscale; PT=Positive treatment subscale; MHP=Mental health problem
CHAPTER 7
128
139
Table 3. Proportion of Agree Responses for DISC Items by Gender
Have you……. Males (N=22)
Females (N=50)
P-Value
Unfair treatment Sub-scale (%) (%) P-Value
Been treated unfairly In making or keeping friends 81.8 82.0 0.985
Been treated unfairly By the people in your neighborhood 50.0 74.0 0.047
Been treated unfairly In dating or intimate relationships 59.1 50.0 0.477
Been treated unfairly In housing 19.0 66.0 <0.001
Been treated unfairly In your education 40.9 28.0 0.279
Been treated unfairly In marriage or divorce 31.8 48.0 0.201
Been treated unfairly By your family 52.4 66.0 0.281
Been treated unfairly In finding a job 36.4 76.0 0.001
Been treated unfairly In keeping a job 31.8 58.0 0.041
Been treated unfairly When using public transport 18.2 18.0 0.985
Been treated unfairly In getting welfare benefits or disability pensions 25.0 47.9 0.080
Been treated unfairly In your religious practices 19.0 30.6 0.319
Been treated unfairly In your social life 42.9 49.0 0.638
Been treated unfairly By the police 27.3 14.3 0.191
Been treated unfairly When getting help for physical health problems 22.7 34.7 0.313
Been treated unfairly By mental health staff 22.7 20.4 0.825
Been treated unfairly In your levels of privacy 18.2 22.4 0.684
Been treated unfairly In your personal safety and security 31.8 63.3 0.014
Been treated unfairly In starting a family or having children 15.0 22.0 0.508
Been treated unfairly In your role as a parent to your children 19.0 36.7 0.144
Been avoided or shunned by people who know that you have a mental health problem 81.0 60.0 0.089
Been treated unfairly in any other areas of life 30.0 42.0 0.351
Stopping self-subscale
Stopped yourself from applying for work 33.3 70.0 0.004
Stopped yourself from applying for education or training courses 28.6 46.0 0.173
Stopped yourself from having a close personal relationship 33.3 76.0 0.001
Concealed or hidden your mental health problem from others 68.2 74.0 0.612
Overcoming Stigma Sub-scale
Made friends with people who don't use mental health services 90.0 77.1 0.217
Been able to Use your personal skills or abilities in coping with stigma and discrimination 75.0 72.9
0.859
Positive Treatment Sub-scale
Been treated More positively by your family 80.0 64.6 0.210
Been treated More positively in getting welfare benefits or disability pensions 15.0 23.4 0.439
Been treated More positively in housing 40.0 22.9 0.153
Been treated More positively in your religious activities 70.0 52.1 0.173
Been treated More positively in employment 50.0 23.4 0.032
Been treated More positively in any other areas of life 65.0 27.7 0.004
Table 7.3: Proportion of Agree Responses for DISC Items by Gender
depression together with other conditions had the highest mean score of overall experienced
discrimination (unfair treatment subscale) (mean=11.9), followed by depression only (mean=8.4),
schizophrenia and other psychotic disorders (mean=8.8), and bipolar disorder (mean=7.1).
Participants unmarried and with one or more children had a slightly higher mean score of overall
experienced discrimination (unfair treatment subscale) compared to those married and without
children respectively (9.8 vs. 8.0 and 9.8 vs. 7.8 respectively). Regarding anticipated discrimination
(stopping self-subscale), females had a higher overall score as compared to males (2.7 vs. 1.7), as
Discrimination, mental disabilities, and employment
129
7
Tab
le 4
. Ass
ocia
tion
betw
een
soci
o-de
mog
raph
ic c
hara
cter
istic
s and
unf
air
trea
tmen
t, st
oppi
ng se
lf, o
verc
omin
g st
igm
a, p
ositi
ve tr
eatm
ent,
and
soci
al fu
nctio
ning
. V
aria
ble
C
ateg
ori
es
Un
fair
Tre
atm
ent
Sto
pp
ing
Self
O
verc
om
ing
Stig
ma
Po
siti
ve T
reat
men
t So
cial
Fu
nct
ioni
ng
Mea
n(S
D)
P-V
alu
e M
ean
(SD
) P
-Val
ue
Mea
n(S
D)
P-V
alu
e M
ean
(SD
) P
-Val
ue
Mea
n(S
D)
P-V
alu
e
Gen
der
M
ale
7.7
(4.4
) 0
.05
3
1.7
(1.3
) 0
.00
3
1.7
(0.6
) 0
.42
5
3.2
(2.0
) 0
.02
0
9.6
(4.8
) 0
.00
1
Fem
ale
10
.0(4
.3)
2.7
(1.1
) 1
.5(0
.7)
2.0
(1.9
) 1
4.1
(5.5
)
Age
3
0 a
nd B
elo
w
8.3
(3.9
) 0
.72
6
2.2
(1.3
) 0
.75
0
1.6
(0.7
) 0
.88
7
2.8
(1.8
) 0
.73
2
11
.0(4
.8)
0.5
50
31
-40
9
.3(4
.9)
2.5
(1.2
) 1
.6(0
.6)
2.3
(2.3
) 1
3.3
(5.9
)
41
and
Abo
ve
9.6
(4.2
) 2
.3(1
.3)
1.5
(0.8
) 2
.2(1
.8)
12
.8(5
.7)
Mar
ital
Sta
tus
Un
mar
ried
9
.8(4
.5)
0.1
18
2
.6(1
.2)
0.0
43
1
.5(0
.7)
0.9
65
2
.3(1
.9)
0.5
98
1
3.6
(5.5
) 0
.05
3
Mar
ried
8
.0(4
.1)
1.9
(1.4
) 1
.6(0
.8)
2.6
(2.1
) 1
0.8
(5.7
)
Nu
mbe
r o
f chi
ldre
n
No
ne
7.8
(4.3
) 0
.11
8
2.1
(1.4
) 0
.35
9
1.7
(0.6
) 0
.35
2
2.9
(1.9
) 0
.26
3
10
.6(4
.1)
0.0
47
One
or
Mo
re
9.8
(4.4
) 2
.5(1
.2)
1.5
(0.7
) 2
.2(2
.0)
13
.8(5
.9)
Ed
ucat
ion
leve
l P
rim
ary
and
Bel
ow
9
.8(4
.2)
0.4
44
2
.1(1
.3)
0.1
00
1
.4(0
.8)
0.0
54
2
.3(2
.1)
0.7
87
1
4.6
(5.7
) 0
.01
6
Seco
nd
ary
and
ab
ove
9
.0(4
.7)
2.6
(1.1
) 1
.7(0
.6)
2.4
(1.9
) 1
1.4
(5.2
)
Dia
gno
sis
Sch
izo
phre
nia
an
d
psy
cho
sis
8
.8(3
.8)
0.0
13
2
.1(1
.2)
0.1
81
1
.5(0
.7)
0.4
81
3
.4(1
.8)
0.1
39
1
0.1
(5.6
) 0
.00
4
Dep
ress
ion
on
ly
8.4
(5.6
) 2
.1(1
.3)
1.4
(0.7
) 1
.6(2
.5)
12
.6(5
.0)
Dep
ress
ion
an
d c
on
dit
ion
s 1
1.9
(3.2
) 2
.7(1
.2)
1.4
(0.8
) 2
.0(1
.7)
16
.0(5
.9)
Bip
ola
r d
iso
rder
7
.1(3
.3)
2.8
(1.0
) 1
.8(0
.6)
2.3
(1.3
) 9
.8(3
.9)
Inte
rest
ed t
o b
e E
mpl
oye
d
Yes
9
.1(4
.3)
0.8
55
2
.3(1
.2)
0.5
31
1
.5(0
.7)
0.2
98
2
.3(1
.9)
0.9
26
1
2.9
(5.8
) 0
.94
3
No
9.4
(4.5
) 2
.6(1
.3)
1.7
(0.6
) 2
.2(2
.0)
12
.8(5
.7)
Tab
le 7
.4: A
sso
ciat
ion
bet
wee
n s
oci
o-d
emo
grap
hic
ch
arac
teri
stic
s an
d u
nfa
ir t
reat
men
t, s
topp
ing
self,
ove
rco
min
g st
igm
a, p
osi
tive
tre
atm
ent,
an
d s
oci
al fu
nct
ion
ing.
CHAPTER 7
130
well as unmarried participants compared to those married (2.6 vs. 1.9), and those with secondary
or higher educational level compared to those with primary or lower level (2.6 vs. 2.1). No relevant
differences were found between socio-demographic characteristics and overcoming stigma
besides a slightly higher mean score in participants with secondary or higher educational level
compared to those with primary or lower educational level (1.7 vs. 1.4). Males had a higher score
in the positive treatment subscale compared to females (3.2 vs. 2.0) and those diagnosed with
schizophrenia and psychosis had higher mean score compared to those diagnosed with other
mental illness (Table 7.4).
141
Table 5. Factors associated with employability.
Variable Categories Unemployed N=40
Employed N=32
P-Value
Age 30 years and below 22.9 3.1 0.014
31-40 years 45.2 34.4
41 years and above 32.5 62.5
Gender Male 22.5 40.6 0.097
Female 77.5 59.4
Marital status Unmarried 75.0 65.6 0.384
Married 25.0 34.4
Children None 30.8 13.8 0.103
With children 69.2 86.2
Education level Primary and below 50.0 38.7 0.343
Secondary and above 50.0 61.3
Type of mental disability Schizophrenia and other psychotic disorders
11.4 27.6 0.341
Depression only 37.1 24.1
Depression and other comorbid conditions
28.6 31.0
Bipolar disorder 22.9 17.2
Interested to be employed Yes 81.6 71.0 0.299
No 18.4 29.0
Think that employment has/would have an impact on your medical outcome/recovery
Yes 86.8 93.5 0.446
No 13.2 6.5
Unfair Treatment 9.5(4.6) 9.1(4.2) 0.698
Stopping Self 2.5(1.3) 2.3(1.2) 0.448
Overcoming Stigma 1.5(0.7) 1.7(0.7) 0.263
Positive Treatment 2.3(2.1) 2.4(1.8) 0.955
Impaired social functioning 14.0(5.1) 11.2(6.0) 0.037
Social functioning levels High 22.5 46.9 0.029
Low 77.5 53.1
Values are percentages for categorical variables and mean (SD) for continuous variables.
Table 7.5: Factors associated with employability.
Discrimination, mental disabilities, and employment
131
7
Social functioning
Mean social functioning score was 12.8 (SD=5.7) and about 2/3 of the participants had low social
functioning (Table 7.2). As shown in Table 7.4, females had higher impaired social function scores as
compared to males (14.1 vs. 9.6) as well as those unmarried compared to those who were married
(13.6 vs. 10.8). Participants with children had higher impaired social functioning as compared to
those without children (13.8 vs. 10.6), as well as participants with primary level of education and
below as compared to those with secondary and above level of education (14.6 vs. 11.4). Those
diagnosed with depression together with other conditions had the highest score of impaired social
functioning (mean=16.0), followed by depression only (mean=12.6), schizophrenia and other
psychotic disorders (mean=10.1), and bipolar disorder (mean=9.8).
Associations between socio-demographic characteristics, experienced and anticipated discrimination,
social functioning, and employment .
The age of the participants was significantly different between unemployed and employed, where
those who were younger were more likely to be unemployed as compared to those who were older
(Table 7.5). Females and those without children were slightly more likely to be unemployed than
males and those with children, respectively.
Although participants who were unemployed reported slightly higher scores of experienced and
anticipated discrimination (unfair treatment and stopping self-subscales) (9.5 vs. 9.1 and 2.5 vs.
2.3, respectively), no significant association was found between discrimination and unemployment.
However, there was an association between impaired social function and employment status.
Those who were unemployed had higher impaired social functioning than those who were
employed (14.0 vs. 11.2 (p=0.037)).
7.4 Discussion
Our study, one of the few carried out in Africa, showed elevated rates of experienced discrimination
among people with mental disabilities, particularly in finding and keeping jobs. Similarly, anticipated
discrimination stopped the majority of the participants from applying for work or education.
Female participants experienced higher discrimination in finding and keeping a job and accessing
education than males, as well as in all the assessed domains of anticipated discrimination including
work and education. Those participants who were unemployed had only slightly higher rates of
experienced and anticipated discrimination. However, we found increased rates of impaired social
function among people with mental disabilities and this was significantly higher in those who were
unemployed.
Our study recorded a higher rate of experienced discrimination than the one reported by
Thornicroft and colleagues in their multi-country study on discrimination (69.7% vs. 29%) [3].
Overall mean scores of experienced and anticipated discrimination in our study were also higher
than those reported in a recent cross sectional study from China (0.9 and 1.4 in our study vs. 0.20
and 0.79 in the study from China, respectively) [22]. These increased rates are rather worrisome
CHAPTER 7
132
and perhaps not surprising on account of the cultural stereotypes surrounding mental illness in
Kenya [23] and in most low income countries [6]. In Kenya, the traditional perception is that
persons with mental illness are mad, insane, violent and likely to harm themselves and others [23].
Our findings highlight the need for interventions in order to reduce stigma towards people with
mental disabilities in Kenya, as well as in similar low income countries, and to mitigate the negative
social and life implications that stigma has on these people. In line with that, there is already some
recent evidence from a pilot study in Kenya that demonstrated the usefulness of an intervention,
following the World Health Organization mental health Gap action Programme guide, in the
reduction of experienced discrimination by persons with mental disorders [5]. Further research
and interventions are needed in particular in low income countries.
Another important and worrisome finding in our study was the gender pattern of stigma. Females
reported higher rates of experienced and anticipated discrimination in work, education, and social
life. This finding was corroborated by a study in Pakistan where women had higher rates of
internalized stigma than men [24]. Similarly, two different studies from India [15] and the UK [14]
reported higher rates of anticipated discrimination in women. Conversely, a Spanish cross-
sectional study showed that men reported more anticipated discrimination than women [25]. In
contrast, no gender differences were found in anticipated discrimination in the multi-country
study by Thornicroft and colleagues [3] and in a cross-sectional study from Nigeria [13]. The
different findings between studies regarding the gender differences in reported anticipated
discrimination and experienced discrimination may be related to several factors specific to socio-
cultural factors (e.g gender roles and local beliefs and practices) in the setting and the illness
specific factors. A study from the US including African Americans participants found that age and
gender differences were reported in attitude, perception, and adopted (religious) coping
mechanisms against mental illness stigma [26].
Although we did not find big differences between discrimination and unemployment in our study,
the observed slightly higher rates of experienced and anticipated discrimination in those who were
unemployed were supported by findings from two multi-country studies [2, 3] where stigma was
identified as a barrier to social and vocational integration. Previous studies also documented a
relationship between mental illness, stigma, and unemployment, and its implication on the lives of
affected individuals [4, 8]. It is possible the experienced and anticipated discrimination were solely
on account of unemployment and not mediated by mental illness. However, we did not explore
these relationship in our study. Employment for persons with mental disability is a human right and
also important for their recovery and social participation [27]. As discrimination against person
with mental illness has been shown to affect work ability and opportunities, the United Nations
Convention on the Rights of Persons with Disabilities (UNCRPD) advocates for equality in
employment [28]. Studies in high income countries pointed to disparities in employment
opportunities between persons with mental disability and the general population [29]. Also
important is the finding by Lasalvia and colleagues who observed that experienced discrimination
was associated with reduced willingness to disclose ones diagnosis with depression [2], which
might work against securing reasonable accommodation in employment [30]. Similarly to this
Discrimination, mental disabilities, and employment
133
7
previous study, our study participants might also be unwilling to disclose their mental illness on
account of the heightened stigma against mental illness in the setting.
We noted that about 2/3 of our study participants had impaired social function and that those who
were unemployed were more likely to have impaired social function than those who were employed.
The association between impaired social function and mental illness is common and had previously
been documented [21, 31]. However, our study reveals its implication for employment and the
well-being of affected individuals for the first time in an African country. Also interesting is the fact
that our study found impaired social function in those with primary level of education and below
compared to those with secondary level of education. This finding strengthens the pivotal
relationship between education and employment, especially in low income countries where higher
or more education is essential for employability [32]. It is pertinent to note that individuals with
depression and other comorbid illness (e.g. substance use) had higher rates of experienced
discrimination and impaired social function scores in our study. This may be due to synergistic
effect of syndemics and calls for greater care for affected individuals on account of the impact of
the multiple disadvantages on their employment opportunities.
Our study is not without some glimmer of hope. Participants reported being treated more positively
by family and in religious activities. This is rather encouraging as two different studies reported
that positive experienced discrimination is rare [3, 33]. The importance of this finding is that family
and religious organisations may serve as a contact point for interventions for stigma reduction in
persons with mental disabilities. This suggestion conflates with the recommended partnership
between faith based organizations and mental health services for the well-being of person with
mental disabilities [26].
The main strength of our study is related to its novelty and being the first in Kenya and to the best
of our knowledge in East Africa. Our exploratory study set out to draw attention to this neglected
group and the barriers of social exclusion they endure. However, our study is limited by the use of
a modest sample size, which might have been underpowered to detect stronger associations
between discrimination and unemployment. Also, our reliance on self-reported questionnaires
may have been affected by memory or recall bias. Thus, responses may have been overestimated
or underestimated; and may not completely reflect the actual experiences of the individuals. It is
possible that the experienced and anticipated discrimination reported by the study participants
were on account of double stigma from both mental illness and unemployment [34]. However, we
were unable to disentangle between these two sources of stigma. Lastly, it is pertinent to note that
the first two items of the social function questionnaire are directly related to work and may have
affected the assessment of the association between social function and employment in this study.
7.5 Conclusions
The rates of experienced and anticipated discrimination faced by persons with mental disabilities
in Kenya is high. The gendered disparity in anticipated and experienced discrimination in
CHAPTER 7
134
persons with mental disability in Kenya may indicate the disadvantages faced by women with
mental disabilities in traditional African societies. Although no strong association was observed
between experienced and anticipated discrimination and unemployment, impaired social
function of persons with mental disabilities seems to have implications for employment. Further
longitudinal and intervention studies are essential to understand the relationship between
discrimination, social dysfunction, and mental illness, as well as measures that might be useful for
improving work life of persons with mental disabilities in particular in low income countries.
Conflict of interest
The authors declare no conflict of interest.
Author contributions
IDE, BJR, and JFGB were involved in the research design. IDE collected the data, analyzed the
data, and wrote the initial draft with MG. IDE, BJR, DMN, JFGB, and MG revised the manuscript.
All authors approved the final version of the manuscript for submission.
Acknowledgement
This work was supported by funding received by IE from the Erasmus Mundus Joint Doctorate
(EMJD) Fellowship-TransGlobal Health Consortium FPA 2013-0039 (SGA2016-1346). The
authors are grateful to Users and Survivors of Psychiatry, Nairobi Kenya, Light for the World
Netherlands and Prof. Sir Graham Thornicroft for sharing materials on stigma and discrimination.
MG is funded by a Miguel Servet fellowship (MS13/00054, CP18/00018) awarded by the
Spanish Institute of Health Carlos III (Ministry of Economy and Competitiveness). ISGlobal is a
member of the CERCA Programme, Generalitat de Catalunya.
Data availability statement
Anonymized data are available upon request from researchers who meet the criteria set out
in the Vrije Universiteit, Amsterdam data policy. Request for data may be made through the
corresponding author.
Discrimination, mental disabilities, and employment
135
7
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Supplementary materials
142
Supplementary material
Supplementary Table 1. Percentage of respondents scoring on each item of SFQ items
Question Response %
I complete my tasks at work and home satisfactorily
Most of the time 27.8
Quite often 16.7
Sometimes 52.8
Not at all 2.8
I find my task at work and at home very stressful.
Most of the time 31.9
Quite often 11.1
Sometimes 47.2
Not at all 9.7
I have no money problems. No problems at all 2.8
Slight worries only 18.1
Definite problems 29.2
Very severe problems 50.0
I have difficulties in getting and keeping close Relationships.
Severe difficulties 30.6
Some problems 20.8
Occasional problems 26.4
No problems at all 22.2
I have problems with my sex life. Severe problems 29.2
Moderate problems 23.6
Occasional problems 23.6
No problems at all 22.2
I get on well with my family and other relatives
Yes, definitely 26.4
Yes, usually 13.9
No, some problems 44.4
No, severe problems 15.3
I feel lonely and isolated from other people.
Almost all the time 26.4
Much of the time 23.6
Not usually 30.6
Not at all 19.4
I enjoy my spare time. Very much 36.1
Sometimes 26.4
Not often 8.3
Not at all 29.2
Supplementary Table 7.1: Percentage of respondents scoring on each item of SFQ items
Discrimination, mental disabilities, and employment
139
7
143
Supplementary Table 2. Responses to individual DISC items
Not at all A little Moderately A lot (%)
Unfair treatment subscale
Have you been treated unfairly in making or keeping friends 18.1 25.0 16.7 40.3 81.9 Have you been treated unfairly by the people in your neighborhood 31.4 14.3 14.3 40.0 68.6 Have you been treated unfairly in dating or intimate relationships 36.7 18.3 13.3 31.7 63.3
Have you been treated unfairly in housing 42.2 6.3 9.4 42.2 57.8 Have you been treated unfairly in your education 64.1 12.5 3.1 20.3 35.9
Have you been treated unfairly in marriage or divorce 45.6 7.0 7.0 40.4 54.4
Have you been treated unfairly by your family 38.0 21.1 14.1 26.8 62.0
Have you been treated unfairly in finding a job 30.3 7.6 12.1 50.0 69.7
Have you been treated unfairly in keeping a job 43.8 14.1 15.6 26.6 56.3
Have you been treated unfairly when using public transport 80.9 10.3 5.9 2.9 19.1
Have you been treated unfairly in getting welfare benefits or disability pensions
49.1 7.3 9.1 34.5 50.9
Have you been treated unfairly in your religious practices 72.5 14.5 2.9 10.1 27.5 Have you been treated unfairly in your social life 52.9 18.6 20.0 8.6 47.1
Have you been treated unfairly by the police 79.0 4.8 4.8 11.3 21.0
Have you been treated unfairly when getting help for physical health problems 68.6 12.9 8.6 10.0 31.4
Have you been treated unfairly by mental health staff 78.9 8.5 8.5 4.2 21.1
Have you been treated unfairly in your levels of privacy 77.9 8.8 5.9 7.4 22.1
Have you been treated unfairly in your personal safety and security 45.7 14.3 11.4 28.6 54.3
Have you been treated unfairly in starting a family or having children 77.8 6.3 4.8 11.1 22.2
Have you been treated unfairly in your role as a parent to your children 62.1 12.1 5.2 20.7 37.9
Have you been avoided or shunned by people who know that you have a mental health problem
31.9 21.7 14.5 31.9 68.1
Have you been treated unfairly in any other areas of life 60.3 16.2 10.3 13.2 39.7
Stopping self-subscale
Have you stopped yourself from applying for work 40.8 12.7 18.3 28.2 59.2
Have you stopped yourself from applying for education or training courses 59.2 11.3 8.5 21.1 40.8
Have you stopped yourself from having a close personal relationship 36.6 11.3 12.7 39.4 63.4
Have you concealed or hidden your mental health problem from others 27.8 13.9 13.9 44.4 72.2
Overcoming stigma subscale
Have you made friends with people who don't use mental health services 19.1 10.3 13.2 57.4 80.9
Have you been able to use your personal skills or abilities in coping with stigma and discrimination
24.2 12.1 16.7 47.0 75.8
Positive treatment subscale
Have you been treated more positively by your family 21.7 15.0 20.0 43.3 78.3
Have you been treated more positively in getting welfare benefits or disability pensions
70.8 8.3 12.5 8.3 29.2
Have you been treated more positively in housing 65.5 10.9 10.9 12.7 34.5
Have you been treated more positively in your religious activities 33.9 8.5 11.9 45.8 66.1
Have you been treated more positively in employment 63.2 12.3 8.8 15.8 36.8
Have you been treated more positively in any other areas of life 55.9 8.5 18.6 16.9 44.1
Supplementary Table 7.2: Responses to individual DISC items
CHAPTER 7
140
144
Supp
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(UT)
In y
our p
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By y
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(UT)
In fi
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Fem
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Discrimination, mental disabilities, and employment
141
7
Published asEbuenyi ID, van der Ham AJ, Bunders-Aelen JFG, Regeer BJ. Expectations management; employer
perspectives on opportunities for improved employment of persons with mental disabilities in
Kenya. Disability and rehabilitation. 2019:1-10.
C H A P T E R 8 EXPECTATIONS MANAGEMENT;
EMPLOYER PERSPECTIVES ON
OPPORTUNITIES FOR IMPROVED
EMPLOYMENT OF PERSONS WITH
MENTAL DISABILITIES IN KENYA
CHAPTER 8
144
CHAPTER 8: EXPECTATIONS MANAGEMENT; EMPLOYER PERSPECTIVES ON OPPORTUNITIES FOR IMPROVED EMPLOYMENT OF PERSONS WITH MENTAL DISABILITIES IN KENYAAbstract
Purpose: In Kenya, employment rate for persons with disabilities is about 1% compared to 73.8%
for the general population, and the situation is even worse for persons with mental disabilities.
Persons with mental disabilities are often regarded as ‘mad’, and stand little or no chance of
employment. We undertook an exploratory study with employers and potential employers to
understand factors that hinder or facilitate their employment and to gain insight into employers’
perceptions of mental disability.
Materials and Methods: We adopted a mixed method study design, including in-depth interviews
(n=10) and questionnaires (n=158) with (potential) employers in Kenya to explore the barriers and
facilitators of employment for persons with mental disabilities.
Results: Out of the 158 employers who completed the questionnaire, only 15.4% had ever employed
persons with mental disabilities. The perceptions that these persons are not productive and may
be violent was associated with an unwillingness to employ them (OR 10.11, 95%CI 2.87-35.59 and
OR 3.6, 95%CI 1.34-9.64 respectively). The possession of skills was the highest reported facilitator
of employing persons with mental disabilities. Employers suggested that information about mental
illness and the disclosure by prospective employees with mental disabilities are relevant for the
provision of reasonable accommodation in the workplace.
Conclusion: Possession of skills and disclosure by persons with mental disabilities could improve
their employability. Information targeted at all actors including employers, employees, government,
and policymakers is necessary in balancing employers and employees expectations.
Keywords: expectations management, employability, mental disabilities, Kenya
145
8
Implications for Rehabilitation
Disabled persons organisations or mental disability programs that seek to improve employment
of persons with mental disabilities should incorporate methods that address employer
expectations through dialogue to find mutual benefits.
Employers require essential information about mental illness, and guidance and support in order
to provide reasonable accommodation in the workplace for persons with mental disabilities.
isabled persons organisations and inclusive employment programs should share the positive
experiences of employers of persons with mental disabilities with employers who are unaware of the
work abilities of persons with mental disabilities to stimulate adoption of inclusive practices.
8.1. Introduction
There are often fewer employment opportunities for persons with disabilities than for the
general population, and the situation is even worse for persons with mental disabilities [1, 2]. In
Kenya, employment rate for persons with disabilities is about 1% [3] compared to 73.8% for the
general population [4]. In the United States, about 10-30% of persons with mental disabilities are
employed [5], while in Europe, employment rate for this group is about 30% [6]. Both common and
severe mental illness are known causes of disability worldwide, and affected individuals experience
significant employment difficulties [7, 8]. Hence, in this study, persons with mental or psychosocial
disabilities refers to individuals with common or severe mental illness that affects their social
or occupational functioning [9, 10]. Low-income and middlle-income countries (LMICs) such as
Kenya, the prospects of employment for persons with mental disabilities are especially poor. A
report by Users of Psychiatry Kenya indicated high rates of unemployment among its members
and overdependence on family caregivers for sustenance [10]. Similarly, the Pan African Network
of People with Psychosocial Disabilities reported a scarcity of formal employment for persons with
psychosocial disabilities on account of stigma and discrimination [11]. These reports are supported
by the initial observations of the Committee on the Rights of Persons with Disabilities, which
stated that in Kenya, only 1% of persons with disabilities are employed [3]. It is pertinent to note
that employment in low- and middle-income countries is largely in the informal sector, such as self-
employment, family business, small privately owned businesses, especially for persons with low skills
[12, 13]. Hence, in addition to the stigma against mental illness, the structure of the labour market
may also be responsible for the challenges of employment for persons with mental disabilities.
To enhance the employment of people with a disability, national and international policies such as
the United Nations Convention on the Rights for Persons with Disabilities (UNCRPD) mandate
employers to offer reasonable accommodation in the employment of a person with a disability
[14]. In its article 27, the UNCRPD urged the recognition of the rights of persons with disabilities
to work without discrimination and for the provision of reasonable accommodation in the work
environment. This approach to disability is captured in the UNCRPD thus: “Recognizing that
Employer perspectives on mental disabilities
CHAPTER 8
146
disability is an evolving concept and that disability results from the interaction between persons
with impairments and attitudinal and environmental barriers that hinder their full and effective
participation in society on an equal basis with others.” [14] For many employers, this creates a
dilemma between fulfilling the requirements of reasonable accommodation for persons with
mental disabilities on the one hand and ensuring productivity and profit on the other [15]. A multi-
country exploratory survey in Europe revealed the willingness of employers to improve inclusion in
the workplace and their need for specialist assistance to provide accommodation in the workplace
for persons with mental disabilities [16]. However, a review by Khalema and Shankar suggested
that globally, the majority of employers are unwilling to employ persons with severe mental illness
on account of their perceived poor work ability [17]. According to Krupa et al. (2009), there are
many myths about the work ability of persons with a mental illness. They include the perception
that persons with a mental illness are unproductive or violent, and may be a liability [18]. These
beliefs constitute a limitation to their employment opportunities and foreclose their participation
in economic activities [17, 18].
In a bid to elaborate on processes to ensure that the desires and expectations of employers and
employees are met, researchers have proposed several methods to include and integrate persons
with mental disabilities in the workplace. For instance, in a randomized clinical trial conducted in
several European countries, Burns and colleagues demonstrated that individual placement and
support were useful for the vocational rehabilitation of persons with a severe mental illness [19].
This approach has been successfully tested in the UK and several other high-income countries.
In mainland China, Zhang et al. showed in a randomized clinical trial that integrated, supported
employment was useful in enhancing employment for persons with schizophrenia [20]. In the
Netherlands, the inclusive redesign of work processes was found to be effective in creating
work opportunities for persons with disabilities [21]. It is pertinent to add that the work support
needs of persons with mental illness may depend on the condition but most importantly on the
specific individual [15]. In all these processes, the cooperation and acceptance of the employer
and information for employers about mental disabilities were shown to be significant for the
successful inclusion of persons with mental disabilities in the workplace [20, 21]. However, studies
showed that employers would employ only those they deemed fit [16, 22, 23]. Although quota
systems for employing persons with disabilities have been used to boost employment in high-
income countries, their usefulness appears limited in low- and middle-income countries due to
weak legislative implementation and a predominantly informal workforce [12, 24]. In addition, it
has been suggested that the quota system may reduce employer behaviour to a mere effort to
complete a checklist rather than the adoption of an inclusive work environment [25].
To date, few studies in low- and middle-income countries have addressed employer perceptions
with respect to the employment of persons with mental disabilities [13, 26]. It is also pertinent
to note that few methods for enhancing the employment of persons with mental disabilities have
been tried in Africa [19, 20]. A scoping review on barriers to and facilitators of employment for
persons with mental disabilities in Africa, reported three methods or facilitators of employment
namely, self-employment, participation in cooperative income generation groups and supported
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employment services [13].
Therefore, we undertook an exploratory study with (potential) employers in Kenya to
understand under what conditions they might employ persons with mental disabilities. Hence,
we sought to: a) gain insight into employers’ perceptions of mental disability; b) explore the
factors that prevented or may prevent them employing persons with mental disabilities; and c)
understand factors that facilitated or might facilitate their employment of persons with mental
disabilities. Bridging the knowledge gap on how to encourage employers to take on their role
in realising the equal employment of people with a disability may be useful in reducing the
high rates of unemployment amongst persons with mental disabilities.
8.2 Methods
Study design, population, and setting
We adopted an exploratory, mixed method study design, using a sequential design [27] involving
the collection of qualitative data through interviews in the first phase which we used to design the
quantitative instrument (questionnaire) for the second phase. The target population consisted of
employers in and around Nairobi, the capital of Kenya.
Sampling
The employers for the qualitative interviews were purposively selected through referral by
persons with mental disabilities who were employed and through employer networks in Kenya
and recommendations of disabled persons organisations in Kenya. The employers were sampled
based on being the business owners or having direct influence over the employment process in
their organisations. Employers and potential employers were sampled from rural and urban
employment settings in and around Nairobi. A total of 200 employers were invited to complete the
questionnaire, and 158 (79%) employers agreed to participate in the study. The questionnaires
were paper based and delivered by the research assistants who waited for the employers to
complete it or came back to collect it depending on the employers preference.
Data Collection
The qualitative study aimed to explore the diversity of employer perspectives related to persons
with mental disabilities. We conducted ten in-depth interviews with employers. The qualitative
interviews were conducted by the IDE and a master student after the provision of study
information. Consent was obtained before every interview. The interviews were semi-structured
and covered their perception of mental disability, perceived barriers and perceived facilitators
for the employment of persons with mental disabilities. The interviews lasted between 30 and 60
minutes, were recorded with an audio-recorder, and were transcribed verbatim. Data saturation
was achieved when no additional information was obtained from the interviews [28].
The quantitative study was conducted to explore the factors associated with (non)employment
of persons with a mental disability further in a larger sample of employers. Findings from the
qualitative study were utilized in the design of the questionnaire. The questionnaire captured the
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socio-demographic characteristics of the employers and covered: a) their perception of mental
disability; b) factors that prevented or might prevent the employment of persons with mental
disabilities, and c) factors that facilitated or might facilitate the employment of persons with
mental disabilities. The questionnaire was pretested on ten employers randomly selected by the
researchers. The questionnaires were self-administered in English or Swahili, the official languages
in Kenya.
Data Analysis and Integration
The interviews were thematically analysed using atlasti version 7.5.18 [29] with a descriptive
open coding strategy. This was done independently by IDE, AJH and BJR, and the final codes and
sub-codes were agreed upon by the researchers. The quantitative data was checked, cleaned and
entered into the Statistical Package for the Social Sciences (SPSS window version 23, Chicago,
Illinois) for analysis. Three levels of statistical analysis were conducted: descriptive statistics,
bivariate and multivariate logistic regression. Exploratory data analysis techniques were used to
uncover the distribution structure of the study variables as well as identify outliers or unusually
entered values. Descriptive statistics were used to examine the general distribution of the
hypothesized factors and outcomes through means, standard deviations, and range for continuous
variables or proportions for categorical variables. Missing values were only reported in the
descriptive statistics but were not included in subsequent analysis. Bivariate association between
employers and non-employers of persons with mental disabilities and their characteristics (socio-
demographics, knowledge, and perception) was estimated using logistic regression models. To
select for potential confounding factors, variables with a P-value less than 0.2 were entered into
the multivariate logistic regression models using the forward method. All tests were two-sided,
and statistical significance was set at P <0.05. All of the analyses were conducted using IBM SPSS
version 23.
Integration of qualitative and quantitative data was ensured throughout the study by an iterative
analysis process involving all the authors. Results were organized according to the main themes
guiding this research: a) employers’ perceptions of mental disability; b) factors preventing the
employment of persons with mental disabilities, and c) factors facilitating the employment of
persons with mental disabilities. In addition, a theme emerged from data on factors related to job
tenure. For each of the main themes, several sub-themes were identified.
Ethics
Approval for the study design was granted by Amsterdam Public Health (WC2017-011) and
Maseno University Ethics Review Committee (MSU/DRPI/MUERC/00391/17). Informed
consent was obtained from all study participants.
8.3 Results
Characteristics of Study Population
The interviewed employers included 7 men and 3 women. The employment sectors included hotels,
the food industry, public organizations, non-governmental organizations, and the construction
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industry. Of the ten employers interviewed, only 2 had knowingly offered employment to persons
with mental disabilities. Two other employers who reported having persons with mental disabilities
in their companies reported that their illness was identified after they had taken up employment,
while the other employers declared they had never employed or worked with persons with a
mental disability.
The sociodemographic characteristics of the 158 employers who participated in the questionnaire
are shown in Table 8.1. Slightly more than half (58.3%) of the employers was female. Nearly half
(49.4%) was aged between 31 and 40 years, with a median (interquartile range) age of 34 (21-69)
years. The overall prevalence of employers who had ever employed persons with a mental disability
was 15.4%, while 29.3% of employers had employed persons with other types of disabilities.
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Table 1: Socio-Demographic Characteristics of the Respondents (N=158)
Variable Category Distribution N (%)
Gender Male 65 (41.7)
Female 91 (58.3)
Missing 2
Age categories 21-30 Years 45 (29.2)
31-40 Years 76 (49.4)
41 -50 Years 23 (14.9)
51 Years and above 10 (6.5)
Missing 4
Age in Years Median (range) 34 (21-69)
Employment Sector Private 153 (96.8)
Public 5 (3.2)
Think that a person with a mental disability should have equal employment opportunities to the general population?
Yes 98 (63.2)
No 57 (36.8)
Missing 3
Ever employed someone with a mental disability in your organization?
Yes 24 (15.4)
No 132 (84.6)
Missing 2
Ever employed people with other forms of disability?
Yes 46 (29.3)
No 111 70.7)
Missing 1
Aware of legislation that mandates employers to employ persons with a mental disability?
Yes 34 (21.9)
No 121 (78.1)
Missing 3
Would you employ persons with a mental disability if this law is enforced?
Yes 99 (64.7)
No 54 (35.3)
Missing 5
Would government support in the form of subsidies encourage you to employ persons with mental disabilities?
Yes 108 (68.8)
No 49 (31.2)
Missing 1
Table 8.1: Socio-Demographic Characteristics of the Respondents (N=158)
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Perceptions of mental disabilities
Employers’ perceptions of mental disability can be assigned to four categories: 1) general typology
and terminology, 2) causes of mental disability, 3) impact on functioning, and 4) general knowledge
and attitudes towards people with mental disabilities. These themes emerged from the survey and
interview data by analysing employers’ responses when asked to define ‘mental disability’.
General typology and terminology
A total of 36% of the responses in the survey provided insight into how employers generally refer
to ‘mental disability’. ‘Disorder’ was the term that employers used most often, referring to mental
disability either as a mental disorder or as a brain disorder (27% of responses in this category).
Employers also regularly used the term ‘condition’, which more generally refers to a certain variation
in state of health or wellbeing (21% of responses within this category). They applied this term in
phrases such as ‘natural condition’ or ‘unusual condition’. Furthermore, employers often mentioned
the term ‘abnormal/not normal’, implying a disruption of normal functioning (17% of answers
within this category). Other terms that were used by a few employers were: ‘illness’, ‘sickness’, and
‘challenged’. Some of them also referred to people with mental disabilities as ‘mad’ and ‘not sound
of mind’. In the interview with one employer, this terminology was also used:
What really comes into my mind when somebody talks about mental illness, to me I think it’s a
mad person. (Employer 6, Female, Hotel manager)
In the interviews, some employers also emphasized the ‘normality’ of mental disability:
Most people are mentally challenged. In fact, almost everybody in life is in their own way to some
percentage, maybe someone is 10% or 5%, mentally challenged. (Employer 1, Male, Restaurant
owner)
Causes of mental disability
When asked to define ‘mental disability’, a total of 29% of all respondents included a reference
to the causal mechanisms of disability. The large majority of these responses (74%) referred to
problems in the brain in terms of ‘brain disorder’, ‘brain dysfunction’, and ‘brain problems’. Some
responses in this category (6%) referred to disability as a psychological problem, pointing to
psychosocial mechanisms causing disability. Another theme included some responses (6%)
referring to ‘problems with functioning of the mind’. Regarding these answers, it remained unclear
how respondents interpreted the concept of ‘the mind’. Another theme included more specific
answers explaining that the condition was due to natural causes, either since birth or by accident.
The interviewed employers rarely referred to causes of disability when asked to explain how they
perceived mental disability.
Impact on functioning
Approximately one-third (35%) of all responses referred to the consequences of mental disability
for a person’s functioning. Half of them (50%) referred specifically to impaired cognitive functioning
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regarding thinking, reasoning, and learning abilities. Respondents used phrases such as: ‘unable to
reason rightly’, ‘can’t think and make decisions’, and ‘slow to learn or to understand things’. Such
associations also emerged in the interviews: “this person is not in a position to make a sound
decision in most cases” (Employer 1, Male, Restaurant owner). A number of other responses in this
category addressed impaired functioning or performance without specifying this further (22%).
Some respondents referred to instability in functioning (5%) or that guidance and assistance were
needed because of impairments in functioning. Another less frequently mentioned theme involved
abnormal behaviour patterns, and respondents described this for example as ‘does not behave
normally’ and ‘acts in a weird way’.
General knowledge and attitudes
When asked in the questionnaire about their thoughts on equal employment opportunities between
persons with a mental disability and the general population, 62% of the employers indicated that
they think persons with a mental disability should have equal employment opportunities. The
interviewed employers also made remarks that gave indications of their general knowledge of and
attitudes towards mental disability in society. Some employers mentioned the importance of an
inclusive, non-discriminatory approach, explaining that people with mental disabilities should be
treated like any other person and should be integrated in society. In addition, approximately half of
the interviewees mentioned a general lack of awareness and understanding about mental illness in
society. One employer said:
I don’t think we have enough awareness, and when people talk of mental disabilities, most people
talk of people who are institutionalized in hospitals. (Employer 6, Female, Hotel manager)
Several employers also mentioned the stigma attached to mental disabilities and explained that
this causes people not to talk about the topic or to avoid people suffering from mental disabilities
and their families.
Yeah, so there is a real stigma for mental issues, people don’t like anything to do with that, it’s too
unpredictable, people don’t understand it. (Employer 9, Female, Law firm HRM manager)
Barriers to employing persons with a mental disability
Employers reported various barriers to employing persons with a mental disability. They include:
reduced productivity, fear or worries related to violence, the recurrent nature of the psychiatric
illness, and attitude of others.
Reduced productivity
Most employers need employees who are capable of meeting their expectations in terms of
productivity, and they believe that persons with a mental illness may be unable to meet those
expectations. Employers expect the best from employees, and the employees’ ability to perform on
the job or meet job expectations determines if they are hired or retained.
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By the time you are engaging someone, it’s really like buying something; it’s just that now you are
buying services of someone. It’s about them being able to perform the work they are really hired to
do. (Employer 7, Male, Chain store manager).
While some employers considered reduced productivity to be a major barrier to employing
persons with mental disabilities, others were concerned that they may be violent in
the workplace on account of their illness.
Fear of violence and safety
The fear of mental illness and the perception that persons with mental disabilities are likely to be
violent was reported by the employers as a major limitation to their employing persons with mental
disabilities. The employers were not just worried about violence, they were also unsure of how to
handle it in the workplace. This fear was expressed by one of the employers as follows:
I think one of the fears is, what if this person gets violent, what do we do? How do we restrain them,
who do we call? Or, what action should be taken within the office to assist this person? (Employer
4, Male, Microfinance manager)
Some other employers revealed through their fears the underlying (mis)understanding about
mental illness and the myths about violence of persons with a mental illness. This was aptly
captured in the following words:
You never know, anything can happen, things keep on changing with them, he can even get
himself in the cooker; so you see I am not discriminating against them, but those are my concerns.
(Employer 7, Male, Chain store manager)
Attitude of others
For other employers, the job environment and the attitude of co-workers were major
limitations to employing persons with a mental disability.
But peers are actually the ones who complain about the inability of these people to handle what
they think is normal. […] Like currently there is someone who is here on such a basis; we are not
very sure but there is a lot of laxity, there is a lot of delay in the delivery… (Employer 1, Male,
Restaurant owner)
The attitude of others was not limited to co-workers; the attitude of customers and clients
is important as they may stop patronizing the business if they discover persons with mental
disabilities have been taken on as employees.
…with our industry it is very sensitive. You are likely to lose your clientele because of such. And
maybe if you had such a person you would have to have them in the back office. (Employer 6,
Female, Hotel manager)
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Facilitators of employing persons with a mental disability
The reported facilitators of employing persons with a mental disability included familiarity with
the affected person/mental illness, skills/qualification of the individual, sympathy or humanity, and
availability of incentives for the employers.
Familiarity and skills of the individual
Most employers suggested that the major determinants to their employment decision are familiarity
with the person and/or their skills. Of the two employers who had ever knowingly employed persons
with a mental disability, the factors that facilitated their action were the skills of the individual
and familiarity. One of the respondents who had employed a lady with bipolar disorder declared:
Hence, the expected reaction of clients and co-workers in the job environment was a reported
barrier to employing persons with mental disabilities. This was perceived by employers as especially
relevant in some job sectors like hotels and supermarkets where the person with a mental disability
would be in direct contact with clients as well as co-workers.
Table 8.2 and present the reasons for not employing persons with a mental disability or factors that
might stop employers from employing persons with a mental disability based on the questionnaire.
Not being productive (51.9%) and fear of violence and safety (50.0%) were the main ones,
followed by the recurrence of the psychiatric illness (30.8%) (Table 8.2). ‘Other reasons’ (6.4%)
and ‘on account of what other workers may say’ (5.1%) were mentioned least. Fear of violence
and safety and non-productivity were the two factors associated with an unwillingness to employ
persons with mental disabilities (OR 3.6, 95%CI 1.34 - 9.64 and OR 10.11, 95%CI 2.87 - 35.59,
respectively) (Table 8.2).
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Table 2: Individual factors associated with unwillingness of employers to employ persons with a mental disability.
Factors That Stopped or Might Stop Employers from Employing persons
with mental disabilities
Variable Category Total Non-Employers of Persons with mental disabilities
OR (95% CI)
N (%) Yes No
N (%) N (%)
The recurring psychiatric illness
Yes 48(30.8%) 40(30.3%) 8(33.3%) 0.87 (0.34-2.20)
No 108(69.2%) 92(69.7%) 16(66.7%) Ref.
Fear of violence and safety Yes 78(50.0%) 72(54.5%) 6(25.0%) 3.60 (1.34-9.64)
No 78(50.0%) 60(45.5%) 18(75.0%) Ref.
They are not productive Yes 81(51.9%) 78(59.1%) 3(12.5%) 10.11 (2.87-35.59)
No 75(48.1%) 54(40.9%) 21(87.5%) Ref.
On account of what other workers may say
Yes 8(5.1%) 7(5.3%) 1(4.2%) 1.29 (0.15-10.97)
No 148(94.9%) 125(94.7%) 23(95.8%) Ref.
Others Yes 10(6.4%) 7(5.3%) 3(12.5%) 0.39 (0.09-1.64)
No 146(93.6%) 125(94.7%) 21(87.5%) Ref.
Note; Ref-Reference category; OR-Odds Ratio; CI-Confidence interval
Table 8.2: Individual factors associated with unwillingness of employers to employ persons with a mental disability.
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I had a bit of knowledge about her condition. In the interview, there were around six ladies and she
was able to beat them because she demonstrated her competence in working with small children.
We therefore decided to give her that employment (Employer 3, Male, Public secondary
school principal)
Similarly, another employer who had paid the tuition of a young male with bipolar disorder in
addition to offering internship employment stated:
The reason I hired him is because I have a condition of my own. Having gone through that
frustration gave me the understanding or the acceptance for somebody else who may be
rejected in another environment. (Employer 2, Male, Architectural firm owner)
Hence, familiarity with the illness or the individual with a mental illness was suggested as a
facilitator to employment. This borders on sympathy and the zeal to give back to society, which
was also reported by the employers as a facilitator of employing persons with a mental disability.
This is also linked to humanity, which the employers regarded as a facilitator to employing persons
with mental disabilities.
Sympathy/ humanity
The desire to ‘touch lives’ is also related to the decision of some employers to fulfil the corporate
social responsibility (CSR) objectives of their organisation. This view was expressed by an
employer who reported that to them, hiring an individual with a mental disability was “…more
of CSR element than it is full-time employment” (Employer 2, Male, Architectural Firm Owner).
The theme of sympathy was also illustrated by another employer who declared:
I also hire to touch a life. So the existence of any business that you have, if you are not touching
lives then you are not doing anything in the society. (Employer 1, Male, Restaurant Owner)
Incentives for employers
Some employers suggested that incentives from the government in the form of grants or
tax rebates would facilitate their decision to employ a persons with mental disabilities.
They suggested that this would cushion the effect of the accommodations they provide for
the individual and the loss in productivity on account of ill health the organisation would
bear. This is vividly described by an employer in these words:
Tax rebates would help because then we can use the money to deal with the salary component of
our obligation. If we can afford not to link his remuneration to the output, then that would allow
us to still retain him in our industry (Employer 2, Male, Architectural firm owner)
Main reasons for employment
The facilitators of employment reported by the employers in the qualitative interviews were
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8Table 8.3 presents the results of the association between socio-demographic, knowledge
and perception variables and employers of persons with mental disabilities. We observed an
association between employers who think that a person with a mental disability should have
equal employment opportunities to the general population and employers of persons with
mental disabilities (OR 4.68, 95%CI 1.32 - 16.52). Those who have ever employed persons
with other forms of disability had higher odds of employing persons with mental disabilities
compared to those who had never done so (OR 6.80, 95%CI 2.65 - 17.43). Employers who have
employed persons with mental disabilities also had higher odds of employing persons with a
mental disability if the law was enforced by the government (OR 3.01, 95%CI 0.97 - 9.35).
Table 8.4 shows that, after adjusting for all factors associated with employers of persons with
mental disabilities at the bivariate level, employers who have ever employed persons living with
other forms of disability had higher odds of employing persons with mental disabilities compared
to those who have never employed them (OR 5.66, 95%CI 2.07 - 15.52). Employers who think
that persons with mental disabilities should have equal employment opportunities to the general
population and indicated that support in the form of subsidies would encourage them to employ
strengthened by the quantitative survey, with the recurrence of familiarity with disability, individual
skills and incentives being likely facilitators of employing persons with mental disabilities.
Figure 8.1 presents the results of the questionnaire regarding the main reasons why the employers
employed persons with a mental disability. The main reason was because of their skills (75%),
followed by sympathy (33.3%), and because they are related to them (12.5%). The categories
‘because of the laws to employ people with mental disability’ and ‘other reasons’ accounted for
only 4.2% each.
Figure 8.1: Reasons for employing persons with mental disabilities (N=24)
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persons with mental disabilities had higher odds of employing persons with mental disabilities
compared to those who said no (OR 3.69, 95%CI 1.41 - 9.60).
175
Table 3: Individual Factors Associated with Employers of persons with a mental disability.
Variable Category Total Employers of persons with mental disabilities
OR(95% CI)
No Yes
N (%) N (%) N (%)
Gender Male 64(41.6%) 53(40.5%) 11(47.8%) 1.35(0.55-3.28)
Female 90(58.4%) 78(59.5%) 12(52.2%) Ref.
Age category 21-30 Years 45(29.6%) 38(29.7%) 7(29.2%) 0.74(0.13-4.23)
31-40 Years 74(48.7%) 61(47.7%) 13(54.2%) 0.85(0.16-4.49)
41 -50 Years 23(15.1%) 21(16.4%) 2(8.3%) 0.38(0.05-3.18)
51 and above 10(6.6%) 8(6.3%) 2(8.3%) Ref.
Employment Sector Private 151(96.8%) 128(97.0%) 23(95.8%) 0.72(0.08-6.72)
Public 5(3.2%) 4(3.0%) 1(4.2%) Ref.
Think that a person with a mental disability should have equal employment opportunities to the general population?
Yes 97(63.0%) 77(58.8%) 20(87.0%) 4.68(1.32-16.52)
No 57(37.0%) 54(41.2%) 3(13.0%) Ref.
Ever employed people with other forms of disability?
Yes 46(29.5%) 30(22.7%) 16(66.7%) 6.80(2.65-17.43)
No 110(70.5%) 102(77.3%) 8(33.3%) Ref.
Aware of legislation that mandates employers to employ persons with a mental disability?
Yes 33(21.4%) 25(19.2%) 8(33.3%) 2.10(0.81-5.45)
No 121(78.6%) 105(80.8%) 16(66.7%) Ref.
Would you employ persons with a mental disability if this law is enforced?
Yes 98(64.5%) 79(61.2%) 19(82.6%) 3.01(0.97-9.35)
No 54(35.5%) 50(38.8%) 4(17.4%) Ref.
Would government support in the form of subsidies encourage you to employ persons with mental disabilities?
Yes 107(68.6%) 88(66.7%) 19(79.2%) 1.90(0.67-5.43)
No 49(31.4%) 44(33.3%) 5(20.8%) Ref.
Note; Ref-Reference category; O.R-Odds Ratio; C.I-Confidence interval
Table 8.3: Individual Factors Associated with Employers of persons with a mental disability.
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Table 4: Multivariate analysis of factors associated with potential employers of persons with mental disability.
Variable Category N (%) A.O.R (95% C.I)
Factors Associated with Employers of Persons with a Mental Disability
Think that a person with a mental disability should have equal employment opportunities to the general population?
Yes 97(63.0%) 3.62 (0.94 - 14.02)
No 57(37.0%) Ref.
Ever employed people with other forms of disability? Yes 46(29.5%) 5.66 (2.07 - 15.52)
No 110(70.5%) Ref.
Aware of legislation that mandates employers to employ persons with a mental disability?
Yes 33(21.4%) 12.9 (0.43 - 3.92)
No 121(78.6%) Ref.
Would you employ persons with a mental disability if this law is enforced?
Yes 98(64.5%) 1.85 (0.53 - 6.43)
No 54(35.5%) Ref.
Factors Associated with Employers Who Think Persons with a Mental Disability Should Have Equal Employment Opportunities to the General Population
Ever employed someone with a mental disability in your organization?
Yes 23(14.9%) 3.41 (0.89 - 13.06)
No 131(85.1%) Ref.
Would you employ persons with a mental disability if this law is enforced?
Yes 97(64.2%) 1.98 (0.77 - 5.04)
No 54(35.8%) Ref.
Would government support in the form of subsidies encourage you to employ persons with mental disabilities?
Yes 107(69.0%) 3.69 (1.41 - 9.60)
No 48(31.0%) Ref.
Note; Ref-Reference category; A.O.R-Adjusted Odds Ratio; CI-Confidence interval
Table 8.4: Multivariate analysis of factors associated with potential employers of persons with mental disability.
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8
Job tenure
Factors identified in the interviews regarding job tenure fall into three categories: performance on
the job, insurance/ guidance, and work adjustments.
Performance on the job
Several employers emphasized the importance of job performance as ‘performance is key’
(Employer 4, Male, Microfinance manager). They want to see that someone is functioning normally
and able to deliver.
We are a performance-driven organization, and for us what really matters is, are you able to
deliver on what you have set out to do or what you’ve been given as your deliverables in a certain
period. (Employer 9, Female, Law firm HRM manager)
However, a larger number of employers mentioned adjusting their expectations of the performance
of people with a mental disability. They either had lower expectations or only expected them to
perform well for aspects they were competent in. In order to be able to adjust their expectations,
employers generally advised that people disclose their mental illness to them.
One employer mentioned the unpredictability of people’s performance and possible inability to
perform as aspects that could lead to dismissal. Another employer specifically mentioned that an
inability to perform or continued periods of absence would be a reason to terminate employment.
Insurance and guidance
Another category of factors entails remarks made by employers about dealing with liabilities they
perceived due to employing someone with a mental disability. Generally, employers wanted an
institution or person to fall back on in case of problems during the employment of a person with
a mental disability. Several employers explained that it is important for them to have some kind of
safeguard or insurance to cover them for possible losses due to the inability to perform or absence
of a person with a mental disability. One employer mentioned already investing in arranging a good
insurance for mental disabilities, which can be hard to negotiate:
Most insurance companies will not cover mental illness and when they do the limit is really low,
you can’t get much out of it. […] So when we are negotiating for those covers we insist, I insist that
it has to come up to at least as high as what they have for other chronic conditions like diabetes
or whatever, if not more, and we have achieved that. (Employer 9, Female, Law firm HRM
manager)
Some employers said they required guidance or support from medical institutions. They wanted
medical professionals to be closely involved during the employment of persons with mental
disabilities, for example by guaranteeing their general fitness for work or by ensuring adherence
to medication.
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They would have to be residing in the institution in such a way that every day before they leave, we
are sure that the person is okay, and in case the person is not able, we even call the employer, that
so and so would not able to report […] and take ownership, takes drugs every day in the morning
before they go to work. (Employer 2, Male, Architectural firm owner)
Lastly, one employer mentioned already investing in counselling services for staff in order to
prevent the possible drop-out of employees due to a variety of issues:
We have outsourced counseling services to basically help our staff cope with those things like
depression, stress and all those others so that they don’t get to the point where they just can’t
manage it. So we highly encourage our staff to take up counseling services before they break, and
that is a service that they take up very well. (Employer 9, Female, Law firm HRM manager)
Work adjustments
Most remarks on job retention referred to aspects at the workplace level. The notion of adjusting
tasks and job descriptions to the person with a mental disability was particularly prominent.
Persons with a mental disability were often assigned to jobs that are less demanding and had
less responsibility or no strict deadlines in order to reduce possible strain. The need for close
supervision at the workplace was mentioned several times. Some employers mentioned assigning
only specific tasks they considered safer or that formed less of a risk for the company, for example
by not having them involved with customers or keeping them away from potentially dangerous
machinery.
And maybe if you had such a person, you would have to have them in the back office because with
the hotel you have front office, these are people who are directly involved with guests, and then we
have back of office. (Employer 6, Female, Hotel manager)
Another way of adjusting work to a person with a mental disability was by generally allowing them
more flexibility in their work schedule or workplace, for example by allowing them to work from
different places.
We have flexi arrangements where basically for whatever reason people feel like they would like
to either come in a bit earlier or leave early. That is an arrangement that we accommodate within
the organization. (Employer 8, Female, NGO HRM manager)
Employers mentioned that disclosure of the mental disability was necessary for them to be
able to allow for such flexibility:
The best is to disclose at the beginning to the employers and how to cope, how they are coping
with the situation so that from the word go, they are putting these people in their proper categories
and not expecting too much of them. (Employer 1, Male, Restaurant owner)
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8
Some stated that they also needed detailed insights into their employee’s capabilities in order to
be able to adjust tasks to that person’s abilities. Lastly, some employers mentioned the importance
of creating an open and accepting atmosphere for people with a mental disability. This may involve
creating awareness among fellow employees about a person’s mental disability:
So as you work with such people, I feel there should be no signs from the employer or the work
colleague that try to indicate there is discrimination or simply showing incapacitation of this
person because when you show this incapacitation, she is likely now to feel that she doesn’t
qualify, to her it will also look like you are demeaning her, which will actually interfere with the
systems such that she is not able to concentrate and move on as she would wish. (Employer 3,
Male, Public secondary school Principal)
8.4 Discussion
In this study, we explored the factors that hinder or facilitate employing persons with mental
disabilities. Previous studies have mainly focused on the attitude of employers to the employment
of persons with mental disabilities [30, 31], but our study takes this further to explore the practices
of employers and their perception of what may help improve the rate of employment of persons
with mental disabilities. We examined the perceptions and experiences of actual employers of
persons with mental disabilities to understand their motivations. Although we know from this
study and others that employers’ perceptions are usually not conducive to employment [32-34],
our study revealed some opportunities. It highlighted an incongruence between an employer’s
belief that persons with a mental disability should enjoy equal employment opportunities to the
general population and the actual practice of not hiring those individuals. This difference between
perceptions and practice is supported by the recommendations of Shove and colleagues, who state
that everyday life and change processes require social practice [35]. In fact, the practice of having
employed persons with other forms of disability was the only predictor of employing persons with a
mental disability in our study. The practice of this category of employers may have been influenced
by experiential knowledge and presents an opportunity for the sensitization of other employers
without prior experience of having employees with disabilities and mental disabilities. This suggests
that facilitating direct contact with employers who hire persons with mental disabilities could be
key in striving for equal employment opportunities.
In this study, we noted that personal experience or understanding of mental illness was a unifying
factor amongst the employers who had consciously employed persons with a mental disability.
The perceptions about mental illness are often dependent on the level of information available
to the individual making the assessment. The pivotal role of information is demonstrated in
its importance in employment models utilized in high-income countries to stimulate the work
integration of persons with mental disabilities [20, 21]. Workplace accommodations using
supported employment or the inclusive redesign of work are dependent on employer awareness,
the health care system, and supportive government policies [20, 21]. These are factors that are
scarce in Kenya and other low-income settings. However, workplace accommodations involve
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conscious employer decisions, which are also dependent on certain local or individual factors such
as disclosure [36, 37]. The employers in our study suggested that workplace accommodations
are only possible if persons with mental disabilities disclose their condition because employers
may only be able to help if armed with information. However, the disclosure action depends on
the individual and may backfire if employers have negative perceptions about mental illness [36].
Hence, some employers in the study suggested that disclosure should be done after the person has
been employed and not at the recruitment stage.
Some employers in this study harboured the fear that persons with mental disabilities would be
violent or unproductive, and these factors were associated with an unwillingness to hire them. The
discrimination exhibited by these employers has been reported in studies that explored the attitude
of employers to individuals with mental disabilities [32, 34, 38]. These negative perceptions about
persons with mental disabilities are integral to the employment decision and may explain the
request for some form of assurance that persons with a disability are ‘OK’ as a precondition to
hiring them, as requested by some employers in this study. The perceptions are also related to the
declaration by other employers in this study that persons with mental disabilities should be hired
to work ‘in the back office’. However, the idea of limiting the type of jobs available to people with a
mental disability might conflict with the right to competitive and desired employment, which is a
fundamental right of every individual as recommended by both the UNCRPD and the sustainable
development goals [14, 39].
Our study highlights the obvious lack of information about legislation on inclusive employment.
Less than a quarter of the employers was aware of legislation mandating employers to employ
persons with mental disabilities, and none of the interviewed employers had ever accessed the
government tax rebates available for employers of persons with disabilities in Kenya. This illustrates
the usefulness of bridging the policy practice gap and how the mere presence of good policies may
not be sufficient if there are no pathways to their implementation and monitoring [23, 40].
Employment of persons with psychiatric disabilities remains a complex social issue with significant
rights and economic dimensions [24, 41]. The UN global compact suggests that inclusive
employment by businesses is a triple win (person with disabilities, businesses, and society) [24].
However, inclusive employment is limited by the stigma of mental illness [42] and the beliefs and
myths associated with mental illness [18, 22, 43]. These perceptions, when shared by employers,
affect the decision to employ persons with mental disabilities [13, 17]. Also, there are issues related
to the individual, mental illness, and social context that affects the employability of persons with
mental disabilities [32, 37]. All these factors are influenced by the mental health system, political
will, and policies operating in the local context.
Based on the findings of this study, we recommend strategies that positively improve the
perceptions of employers regarding the employment and return to work of persons with mental
disabilities. This may be achieved via dialogue (between employers and disability organisations)
and reconstruction of the social role and expectations associated with persons with mental
Employer perspectives on mental disabilities
161
8
disabilities and other disadvantaged groups [44, 45]. Also, we recommend further research on how
to strengthen return to work for persons with mental disabilities after episodes of illness.
Our study showed that mere legislative recommendations and punitive laws may be unable to
improve the practice of inclusive employment as much as personal understanding of the need
for change. The positive experience of the employers who have employed persons with a mental
disability needs to be shared and held up to convince the group of employers holding onto myths
about the work capability of persons with mental disabilities. This illustrates the importance of
in-depth insight into the realities of employers which our study sought to explore. Our study also
revealed employers’ concerns and need for reassurances through job coaches and support that
assists persons with mental disabilities to stay at work. This may point to a lack of information about
mental illness and a genuine need for direction. However, it may also be related to a perception
of a devalued work role of persons with mental disabilities [44, 45]. Striving for normalisation of
the employment of persons with disabilities through facilitating direct contact and experience
among employers could prove useful for reconstructing work roles. Yet, it is pertinent to consider
that normalisation of mental disabilities as observed by Scheid [38] may in fact deprive affected
individuals of the accommodation that they need. The role of job coaches and support for persons
with mental disabilities is in line with supported employment, which has been found relevant
for work integration. It is useful to highlight the pivotal role of health care in this process, as
demonstrated in other inclusive employment models [20, 21], because work may be impossible
without health.
Hence, expectation management to improve the employment of persons with mental disabilities
is two-sided. First, the employers need to be informed about the work capability of people with
mental disabilities, (inter)national regulations, possibilities to provide accommodation, and the
benefits of employing people with a mental disability. Second, society’s expectations of employers
need to be managed by taking into account the realities of entrepreneurs; decisions on hiring staff
require careful considerations that involve weighing a range of factors, including productivity and
continuity of the business.
In spite of the strengths and findings of this study, we acknowledge certain limitations as well.
The narratives of the employers may be affected by social conformity rather than their actual
situation. The results represent the perceptions of the actual employers we recruited for the study
and may differ for employers in other settings whose social context is different. Although our
employers were all in Nairobi which is the capital of Kenya, we were unable to stratify them into
urban, suburban or rural areas. In addition, most of the employers were from the private sector
because employers from public or government organisations required either further approval or
permission from their organisation to speak to us or complete the questionnaire.
8.5 Conclusion
The employability of persons with mental disabilities is a complex issue and dependent on a
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set of interrelated factors aside from employers (the person with a mental disability and the
socio-political environment). The employers’ perceptions about mental illness may affect the
employment of persons with mental disabilities. However, it is also pertinent to note that the
employers’ expectations in terms of productivity, especially in resource-poor settings with
economic challenges, may limit their possibilities for corporate social responsibility. Hence, while
programs that aim to improve employment for persons with mental disabilities should consider
processes that improve employers’ perceptions as an intervention strategy, it is also important
that government policies evolve a favourable economic environment to encourage employers. In
addition, policies like tax rebates or subsidies may increase the disposition of employers to a more
inclusive employment practice.
Authors contribution
IDE, JFGB and BJR were involved in study design. IDE conducted the data collection while IDE,
AJH, JFGB and BJR were involved in data analysis. IDE and AJH wrote the initial draft all authors
reviewed and approved the final draft of the manuscript.
Acknowledgements
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium FPA 2013-0039 (SGA2016-
1346). The authors are grateful to all the study participants and to Giovianca Felix for her support
in the data collection. We thank. Dr Mònica Guxens for reviewing the draft of the manuscript. We
also thank the anonymous reviewers of the manuscript.
Declaration of interest
The authors declare no conflict of interest.
Prior presentation
Presented as an abstract on November 23 2017 at the 2nd Annual Meeting of, Amsterdam Public
Health, Amsterdam, The Netherlands.
Employer perspectives on mental disabilities
163
8
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Under reviewEbuenyi ID, Regeer BJ, Aguocha C, Bunders JFG, Guxens M.Perspectives of mental health care
providers on pathways to improved employment for persons with mental disability in two low
income countries. International Journal of Mental Health Systems.
PERSPECTIVES OF MENTAL
HEALTHCARE PROVIDERS ON
PATHWAYS TO IMPROVED
EMPLOYMENT FOR PERSONS WITH
MENTAL DISABILITY IN TWO LOWER
MIDDLE-INCOME COUNTRIES
C H A P T E R 9
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9. PERSPECTIVES OF MENTAL HEALTHCARE PROVIDERS ON PATHWAYS TO IMPROVED EMPLOYMENT FOR PERSONS WITH MENTAL DISABILITY IN TWO LOWER MIDDLE-INCOME COUNTRIES Abstract
Background: Mental illness affects employment and the ability to work, and mental healthcare
providers are important in the promotion of health and employment for persons with mental
disability.
Objective: To explore the perspectives of mental healthcare providers on pathways to improved
employment for persons with mental disability in two lower middle-income countries.
Methods: Our study participants included mental healthcare providers (psychiatrists, occupational
physicians, psychologists, and social care workers) from Kenya and Nigeria. Qualitative interviews
and a focus group discussion were conducted with 15 professionals in Kenya and online
questionnaires were completed by 80 professionals in Nigeria.
Results: The study participants suggested that work is important for the recovery and wellbeing
of persons with mental disability. A complex interplay of factors related to the health and
socioeconomic system were identified as barriers to employment for persons with mental disability.
Participants proposed four pathways to improved employment including information on reducing
stigma, better health care, policy advocacy in employment, and government commitment to health
care and social welfare. Public education to reduce stigma and better health care were the highest
reported facilitators of employment.
Conclusions: Persons with mental disabilities require multilevel support and care in obtaining
and retaining employment. A better mental healthcare system is essential for the employment of
persons with mental disability.
Key words: healthcare providers, work ability, employment, improved health care, government
commitment
Perspectives of mental healthcare providers on employment
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9.1 Introduction
At the global level, studies indicate that mental illness adversely affects employment and the ability
to work [1, 2], and the rate of employment is higher for those who are receiving treatment [3, 4].
Work ability refers to the extent to which a person is physically or mentally fit to meet the demands at
the workplace [5], and it is affected by both common and severe mental disorders [3, 6]. In common
parlance, work ability can also be expressed as a person’s ability to work. Health professionals
such as psychiatrists and psychologists are important in the promotion of employment for persons
with mental illness [2, 7-9]. Their provision of care and support is pivotal to recovery and the
ability to work [8, 10]. In the work environment, occupational health physicians and therapists
also contribute to workers’ health and wellbeing by providing advice on mental health care and
promotion [11-14].
Despite the suggestion in some studies that mental illness can lead to impaired social and
occupational functioning [15], controversy and challenges remain in the certification of disability
as it is sometimes keenly contested by society, persons with mental illness, and mental healthcare
providers [14, 16]. In the United States, this has been a subject of several court cases despite
the guidance provided by the Americans with Disabilities Act [17]. In South Africa, persons with
mental disabilities still face an uphill task in obtaining the disability certificate they need to obtain
social benefits [14]. In Kenya, the process is protracted and difficult [18], while in Nigeria, persons
with mental illness are not regarded as living with a disability [19]. These challenges are barriers
to mental health interventions in the workplace and integrated rehabilitation services that are
essential for the employment of persons with a mental disability [20, 21].
Health professionals are scarce and this is worse for mental health care [22]. In high-income
countries, persons with mental illness mainly face demand-side barriers to health care [23].
Conversely, in low-income countries, both demand and supply-side barriers affect access to and
the uptake of mental healthcare services [24, 25]. In addition to the challenges in the health
system, studies suggest that health professionals may have a negative attitude towards persons
with mental illness [7, 26, 27], while also having an important part to play in their employment [7,
10, 26-28].
Despite the all-important role of mental healthcare providers in the employment of persons with
mental disability, we are unaware of any study in Africa that has explored the perspectives of mental
healthcare providers and occupational physicians on the ability of persons with mental disabilities
to hold down a job. One study in Nigeria explored the attitude of doctors in general to persons with
mental illness [7]. Our study takes this further by exploring specifically the perspective of doctors
involved in treating patients with mental illness and work to identify pathways to change. This
study aims to explore the perspectives of healthcare providers on employment of persons with
mental disabilities in low-income countries and suggest pathways to their improved employment.
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9.2 Methods
Study design and population
We set up two studies: a qualitative study involving semi-structured interviews and a focus group
discussion (FGD) in Kenya; and a quantitative study involving online questionnaires in Nigeria.
The qualitative study involved mental health professionals (psychiatrists, psychologists, and
social care workers) purposively selected from the department of Psychiatry at the University
of Nairobi Teaching Hospital in Kenya. Fifteen mental health professionals were involved in the
interviews (n=10) and one FGD (n=5). The participants were purposively selected based on their
professional experience and some of them also worked and provided mental health services at
Mathare Referral Hospital, which is the major in-patient public mental health hospital in Kenya.
The quantitative study used an online questionnaire [29] which was shared with psychiatrists
and occupational/community health physicians in Nigeria. The questionnaire was shared through
the social media platforms (WhatsApp and Facebook) of the Nigerian Medical Association and
National Association of Resident Doctors. A total of 80 participants completed the questionnaire.
Kenya and Nigeria are similar in terms of the unmet needs for mental health care (MHGAP) and
in this study both settings were used to elicit views on the employability of persons with mental
illness in low-income settings [30].
Data Collection
The qualitative data collection involved in-depth interviews which explored: perspectives on the
ability to work of persons with mental disabilities; perceived barriers to employment of persons
with mental disabilities; and perceived facilitators of employment for persons with mental
disabilities. The mental health professionals were encouraged to share the common factors with
those of their patients who were employed and what they thought would improve employment
opportunities for those who had no job. The interviews lasted between 30 minutes and an hour
and were conducted by IDE (who is also a doctor) and an intern master’s student in public health.
The FGD was conducted with five mental health professionals and was facilitated by IDE. When
data saturation [31] was achieved, no further participants were invited to be interviewed. The
FGD lasted between 60-90 minutes and aimed to validate and enrich the findings from interviews.
The interviews and FGD were recorded and transcribed verbatim. The participants were provided
with study information and their consent was also obtained.
The online questionnaire was researcher-designed using Google Form. It consisted of both
open-ended and closed questions. It explored the perspectives of psychiatrists and occupational/
community health physicians on the ability of persons with mental disabilities to work and
perceived barriers to and facilitators of their employment. The questionnaire also explored the pre-
employment assessment of mental illness, accommodation made for persons with mental illness
at the workplace, and what employers can do to improve employment for persons with mental
disabilities. The study information was provided and completion of the survey was regarded as
consent to participate in the study.
Perspectives of mental healthcare providers on employment
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9
Perspectives on the ability to work of persons with mental disabilities
The mental healthcare providers involved in the interviews and FGD stated that they consider
mental illness as a source of disability and that persons with mental disabilities can and should
work. In addition, they revealed that in their clinical practice, they routinely encourage them to
work when they are clinically stable because they considered it useful for recovery. One study
participant stated that ‘I do very much try to encourage the patients to try to regain their original levels of
Data Analysis
The qualitative data was imported into Atlas.ti version 8 and analysed thematically [32]. Data was
independently coded by IDE and CA and discussed with MG, BJR, and JFB. The differences were
discussed after which the final themes emerged.
For the quantitative analysis, descriptive statistics were used to explore the socio-demographic
characteristics of the healthcare providers, and their perceived barriers to and facilitators of
employment for persons with mental disabilities. The analysis was conducted using IBM SPSS
version 23 (IBM, New York).
9.3 Results
Socio-demographic characteristics of study participants
Table 9.1 outlines the socio-demographic characteristics of the study participants. Of the 15
participants in the qualitative study, four were psychiatrists, nine psychologists, and two social
workers. Of the 80 healthcare providers who participated in the quantitative study, 43 were
psychiatrists, 11 occupational health physicians, 19 community health physicians while seven did
not state their profession. Their mean years of practice was 8.7; and 37.5% had practised for more
than 10 years.
182
seven did not state their profession. Their mean years of practice was 8.7; and 37.5% had practised
for more than 10 years.
Table 1: Socio-demographic characteristics of healthcare providers
Qualitative study (n=15)
Profession Interviews Focus Group Discussion Psychiatrist 4 - Psychologist 4 5 Social worker 2 -
Quantitative study (n=80) Variable Category Distribution* Sex Female
Male Missing
28 (35.4) 51 (64.6) 1
Age (years) 37.9; 37; 27-64 Profession Psychiatrist
Occupational Health Physician Community Health Physician Other
43 (53.8) 11 (13.8) 19 (23.8) 7 (8.8)
Fellowship status Completed residency Currently doing residency Not applicable
31 (38.8) 45 (56.3) 4 (5.0)
Years of practice Years in continuous Less than 10 years More than 10 years Missing
8.7; 7; 3-27 49 (61.3) 30 (37.5) 1
*Values are N (percentage) for categorical variables and mean; median; range for continuous variables
Table 9.1: Socio-demographic characteristics of healthcare providers
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functioning and to try as much as possible to maintain their jobs’ (Healthcare provider 4_Psychiatrist).
However, they also stated that not all persons are able to work because of specific individual
challenges. This idea was captured in a statement made by one study participant who declared
that ‘There are ones I have seen who are employed and others who are not employed because of different
reasons’. (Healthcare provider 2_Psychologist).
In the quantitative study, 96.2% of the healthcare providers believed that persons with mental
disabilities can work and 76.3% said they have persons with mental disabilities at their workplace
(Table 9.2). When asked whether they thought such persons posed a risk at the workplace, 91.3%
said sometimes and 7.5% said never. The majority (86.3%) of the healthcare providers felt they had
a role in enhancing job opportunities for persons with mental disabilities. Early intervention and
rehabilitation (39.1%) and public education to reduce stigma (25.0%) of mental illness were most
reported. When asked to suggest conditions under which persons with mental disabilities can work,
the responses ranged from under supervision (27.8%), when clinically stable (26.4%), when on
treatment or medication (16.7%), unsupervised like other people (11.1%), when they want and have the
capacity to work (8.3%), and when they have the capacity to work in a sheltered setting (1.4%).
Perceived barriers to employment of persons with mental disabilities
In the qualitative study, the healthcare providers identified various interrelated barriers to the
employment of persons with mental disabilities, of which five major clusters were mental illness,
dysfunctional health system, social stigma, socioeconomic status, and lack of government or policy
commitment.
Mental Illness
The mental healthcare providers suggested that factors related to the peculiar nature of the
mental illness were a major barrier to employment and ability to work of persons with mental
illness. Given its recurrent nature, and its ability to impair social and occupational functions, it
limits individuals’ desire for a job and being productive at work. This limitation also affects those
who were on treatment and suffer the side-effects of psychiatric medication. The illness and the
effects of the medication were perceived to be related to the lack of interest or ability to work
among persons with mental disabilities.
When you are given some of the drugs you sleep and you cannot function so that one causes
another issue of utilizing both mental health facility and looking for employment among people
who are mentally sick. (Health Care Provider 3_Psychatrist)
It is ironic that both the illness and the required cure may produce the same impact regarding
employment. The side-effects of medication may lead to non-compliance, which worsens the
effects of the illness and further reduces functionality or work ability.
Dysfunctional Health System
All mental healthcare providers agreed that mental health care is neglected and that the system
is sub-optimal, manifested in the paucity of mental healthcare services, unavailable and expensive
Perspectives of mental healthcare providers on employment
173
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184
Table 2: Perspectives on ability to work of persons with mental disabilities
Variable Category Distribution N (%)
Do you have persons with mental disability at your workplace?
No 4 (5.0)
Yes 61 (76.3)
I do not know 15 (18.8)
Do you think persons with mental disability can work?
No 3 (3.8)
Yes 75 (96.2)
Missing 2
Do you think persons with mental disability pose a risk at work?
Always 1 (1.3)
Never 6 (7.5)
Sometimes 73 (91.3)
Are there things you can do to enhance jobs for persons with mental disability?
No 11 (13.8)
Yes 69 (86.3)
What are things you can do to enhance job opportunities for persons with mental disability?
Public education to reduce stigma of mental illness
16 (25.0)
Early intervention and rehabilitation 25 (39.1)
Demonstrating ability to work of persons with mental disability
4 (6.3)
Supportive work environment 6 (9.4)
Policy advocacy and affirmative action
4 (6.3)
Education of employers 3 (4.7)
Others 6 (9.4)
Missing 16
Under what conditions should persons with mental illness be allowed to work?
Under supervision 20 (27.8)
When clinically stable 19 (26.4)
When on treatment or medication 12 (16.7)
Unsupervised like others 8 (11.1)
In sheltered work settings 1 (1.4)
When they want and have the capacity to do the job
6 (8.3)
Others 6 (8.3)
Missing 8
Table 9.2: Perspectives on ability to work of persons with mental disabilities
essential medication, and lack of insurance for mental health. The lack of available mental health
care means there are very few psychiatrists and psychologists, especially in rural areas. In addition,
because there is only one in-patient mental health service in Kenya, people tend to it avoid because
of stigma, and so prefer a private health service they cannot sustain in view of the chronic nature
of mental illness.
Our public mental health hospitals are few and people avoid them because there are so many
patients within public hospitals and the resources are less staff who are overwhelmed; so they
may not offer friendly services and have little time for the patients… (FGD _Psychologist)
The problem of medication was also highlighted. Even for patients who choose to go to private
hospitals and have public health insurance, the lack of essential medicines in the hospitals forces
them to still make out-of-pocket payments for medication. The healthcare providers also noted
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that the few available medications in the public hospitals have a huge spectrum of side-effects
which indirectly affects a person’s ability to work.
I think access to medication is a problem but is no longer such a big problem…the bigger barrier is
lack of purchasing power which leads to inability to buy medications and adherence to treatment.
(Healthcare provider 9_Psychologist)
These medication challenges are also related to unwillingness of insurance companies to offer
cover to persons with a mental illness because it is perceived as a chronic illness, a pre-existing
illness or related to alcohol use.
I think poor health care utilization is related to finance because health care insurance does not
cover mental illness... Insurance companies are still discriminative of persons with mental illness.
(Healthcare provider 3_Psychiatrist)
Social stigma
The study participants suggested that widespread stigma against persons with mental illness may
have implications for their ability to work and employment opportunities. According to them, the
stigma emanates from the family, community, employers and mental healthcare providers. This
heightened stigma is perceived to be related to cultural perceptions and lack of understanding of
mental illness leads to social isolation and exclusion.
So, the society feels like you are not one of us and therefore you are not accepted among us, it’s like
you are an outcast. So, because of that definitely one is stigmatized and you cannot be allowed
even to work in our [midst]… even the government itself does not allow many of these people, it
does not employ them. (Healthcare provider 1_Psychologist)
The stigma is also encountered among employers who may fire an individual on the grounds even
of common mental health disorders such as anxiety.
So, I think the biggest barrier really in addition to money is the stigma around mental health. ….
you don’t even have to be psychotic, having something as simple as anxiety, depression can get
you fired and you are never getting a job again. (Healthcare provider 10_Psychologist)
The stigma is not restricted to employers or social perceptions, but also happens in hospitals among
the healthcare providers charged with caring for patients and improving their ability to work. This
was aptly captured by one of the study participants: ‘People with mental illness go through a lot of
stigma that stops them from seeking care or going to school…. And even when they come to seek care, they
would receive stigmatization from the people treating them…’ (Healthcare provider 9_Psychologist).
Low socioeconomic status
The healthcare providers suggested that critical to employment is the socioeconomic status of
the individual, since this determines whether the individual is educated, has the required skills to
qualify for employment and the money to set up their own business. One study participant stated:
Perspectives of mental healthcare providers on employment
175
9
‘For me, there is a correlation between socioeconomic status and work ability, because if you are not able
to access good health care, meaning even the treatment will be poor, meaning even for you to work is also
a challenge… (Health care provider 7_Social worker).
This point is further elaborated by the study participants in their comparisons of their patients
who are foreign or have a higher socioeconomic status and those who have a low socioeconomic
status. According to them, patients with a higher socioeconomic status do not face the challenges
of securing or retaining job and this may be related to the stability of their illness, ability to obtain
care and often higher educational level, all of which are also useful for employment and ability to
work.
Those who are poor let’s say those who are quite poor most probably you are not going to get
even that employment, and then that means probably you will become more poor. But those
who are a little bit wealthy, I think they have better services, they are given better services even
in the hospitals because they are able to access the best psychiatrist for example and they get
proper medication. And I think also those who are wealthy also kind of look at it as an illness, it’s
not just like, it’s not something that people don’t understand what it is. (Healthcare provider
1_Psychologist)
The predicament of the person of low socioeconomic status is thus like a vicious circle in which they
are unable to help themselves. Another study participant declared that ‘… money is an issue. You see
these persons may go home and they have the medication. But one month later, there is no money to buy
the medication so they are psychotic again and cannot work…’ (Healthcare provider 10_Psychologist).
Lack of government and policy commitment
Lack of government and policy commitment was identified as a major limitation to work
opportunities for persons with mental disabilities because of its relationship to health care and
social welfare. Government apathy may explain the failure to implement policies and healthcare
commitments, the absence of enforcement mechanisms to ensure inclusive employment and
discriminatory health insurance scheme, and the lack of functional essential medicines in public
hospitals. The mental healthcare providers suggested that government commitment and
investment in mental health care is poor.
We are fighting for health from all angles and that is a big challenge not only for mental health
sector. Budgetary allocation for health itself is bare minimum now start thinking mental health…
(Healthcare provider 5_Psychiatrist)
This low investment in health has implications for access to or uptake of mental health care, which
also affects the ability to work of persons with mental disabilities. According to them, this lack of
commitment is evident in the dysfunctional mental healthcare services, which makes it possible for
only the middle class with more disposable income to obtain mental health care and health care in
general. They further highlighted the difficulties of managing mental health care without health
insurance.
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….they don’t have insurance they don’t have the money then they don’t come for clinic they don’t
come for follow up and yeah so they are at a disadvantage. (Healthcare provider 5_Psychiatrist)
The government and related factors interact with problems in the work and social environment to
influence employment opportunities for persons with mental disabilities.
Table 3 shows that 11.3% of the participants of the quantitative study reported that pre-employment
assessment of mental illness affected employment opportunities for persons with mental illness;
yet it was also perceived as one of the reasons for the absence of workplace accommodation. The
majority of respondents (77.3%) said that pre-employment assessment of mental illness was not
applicable in their workplace. This observation was also reported in the qualitative study where
the respondents said it was uncommon to make a pre-employment assessment of mental illness.
They also suggested that they do not advise their patients to disclose their mental health status
because of the likelihood of stigma. A psychiatrist stated: We don’t encourage them to fully disclose,
yeah. We think they need to be strategic about... because most of the time it would jeopardize their job
opportunity (Health care provider 4_Psychiatrist).
Although 76.3% of the participants in the quantitative study reported that they have persons with
mental illness in their workplace, only 15% have made the relevant workplace accommodation.
Perceived facilitators of employment for persons with mental disabilities
The mental healthcare providers suggested that greater employment for persons with mental
disabilities is possible through the combination of several factors acting together. Four clusters
of factors were identified including information on stigma reduction, improved health care, policy
advocacy on employment, and government commitment to health care and social welfare.
Information of stigma reduction
The healthcare providers suggested that providing relevant information on mental illness would
help reduce stigma against persons with mental illness. This information would be aimed at
individuals in society, employers, mental healthcare providers, and policy-makers. The expected
ripple effect of information and relation to improved employment is evident in the words of one of
the study participants who declared:
If stigma is reduced and even employers are able to understand about mental illness that when
they are stable they are able to work; when they are sick, they get treatment, I think that could
help. If employers are understanding [about] of mental conditions, that would enable them to
recover. (Healthcare provider 9_Psychologist)
The critical nature of educating society about mental illness is further captured in the statement:
‘…So I think first we need to educate the society to know about mental illnesses. That is key so …that
people would feel free to seek employment. Because there are those who are sick but they are afraid of
going to seek employment and there are those who are not even ready even to disclose because of the fear.
So, first is sensitizing the society to know that this illness is like any other illness’ (Healthcare provider
1_Psychologist).
Perspectives of mental healthcare providers on employment
177
9This perception of the importance of information to reduce stigma is supported by the quantitative
study, where public education to reduce stigma was the highest reported factor that could improve
job opportunities for persons with a mental disability (27.3%) (Table 9.3).
Improved health care
The healthcare providers advocated improved health care as a way to enhance the ability of
persons with mental disability to find work. They suggested that a better health system would
ensure the availability of optimal and affordable care, which would indirectly enhance adherence
to treatment and ensure a stable clinical state that is relevant for work ability.
Health institutions and professionalism are also key; so that people can access care and also in a
non-judgmental manner….we have very few facilities around which deal with mental health like
for example now we have only Mathare, so we need more of those kind of facilities. We need also
189
Table 3: Perceived barriers and facilitators to employment of persons with mental disabilities
Variable Category Distribution N (%)
Do you have pre-employment assessment at work? No 71 (88.8)
Yes 9 (11.3)
How often has pre-employment assessment affected opportunities at your workplace?
Never 8 (10.7)
Not applicable 58 (77.3)
Sometimes 9 (12.0)
Missing 5
Is there workplace accommodation at your workplace?
No 68 (85.0)
Yes 12 (15.0)
What factors can enhance the job opportunities for persons with a mental disability?
Public education to reduce stigma of mental illness
21 (27.3)
Early diagnosis and treatment 18 (23.4)
Improved health care for persons with mental disability
6 (7.8)
Supportive work environment 8 (10.4)
Family support 2 (2.6)
Policy advocacy and affirmative action
9 (11.7)
Formal education and training for persons with mental disability
7 (9.1)
Other 6 (7.8)
Missing 3
Why is there no accommodation for persons with a mental disability at your workplace?
I don’t know 9 (20.5)
No pre-employment assessment 1 (2.3)
No provisions by employer/management
9 (20.5)
Lack of awareness of its usefulness 5 (11.4)
Non-disclosure of mental illness at employment
2 (4.5)
Financial constraints 3 (6.8)
Neglect of mental illness 5 (11.4)
Other 10 (22.7)
Missing 36
Table 9.3: Perceived barriers and facilitators to employment of persons with mental disabilities
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even rehabilitation centres… (Healthcare provider 1_Psychologist)
The theme of advocacy for improved care and professionalism was also closely related to the need
of healthcare providers to protect patients and cater for their health needs. One participant stated:
‘Part of advocacy is protecting the patient. So, we cannot say that we are advocating for improvement to
health care while not protecting the patient’ (Health care provider 10_ Psychologist).
This perspective on improved mental health care was also echoed in the quantitative study where
early diagnosis and treatment of mental illness was the second-highest reported factor to enhance
ability of persons with mental illness to work (23.4%) (Table 9.3). Also, 7.8% of the healthcare
providers reported that improved health care was relevant for job opportunities for persons with
mental disabilities.
Policy advocacy on employment
The study participants identified the importance of a supportive work environment and suggested
that practical policies to enhance reasonable accommodation would enhance both employment
and retention in jobs for persons with mental illness. They advocated affirmative action in the
employment of persons with mental illness and close collaboration with employers to ensure
that disclosure does not lead to stigma but aids in the provision of workplace accommodation: ‘…
with support, if these people can be supported then they are able to progress but when they are in an
environment where people do not understand what is all about mental illness…’ (Healthcare provider
7_Social worker).
The mental healthcare providers advocated for local companies to emulate the employment
polices of international companies that not only employ persons with mental disabilities but also
provide them with mental healthcare packages.
And because they don’t know what to do with you they would rather not employ you so that is
further stigmatization they are experiencing. But the international companies and institutions I
think they kind of understand this kind of condition. Like for example I have dealt with a number
of international kind of institutions and there are a number of the patients they brought me or
clients who have been in war-torn areas where there is a lot of fighting and majority of them
have post-traumatic stress disorder. So when they come they actually bring them for help and
without the intention of sacking them after treatment. But then the local companies sometimes
are very shallow understanding about even how to deal with these people. (Healthcare provider
1_Psychologist)
This idea was also supported by the healthcare providers in the quantitative study who identified
a supportive work environment (10.4%) and policy advocacy and affirmative actions (11.7%) as
factors that can enhance employment of persons with mental disabilities (Table 9.3). In order
for employers to provide reasonable accommodation in the workplace, some participants
recommended that disclosure might be useful in order to for employers to help employees with
mental disabilities. One of the participants stated: ‘I think disclosure to people who are your support
Perspectives of mental healthcare providers on employment
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9
is important; I think it’s a must’ (Healthcare provider 1_Psychologist). It is pertinent to note that this
suggestion to disclose was perceived as advisable only after the individual has gained employment,
as stated earlier.
Government commitment to health care and social welfare
Government commitment to health care and welfare is central and related to most of the factors
that are relevant to greater employment of persons with mental disabilities. This is because
government commitment would ensure that all the limitations in the health system, including
addressing the shortage of mental health professionals, non-availability of essential mental health
medications and rehabilitation services, and discriminatory health insurance practices. This crucial
role of the government is captured in the statement:
...first of all, the government needs to see mental illness as something that needs to be addressed
by coming up with a mental health policy and integrating into it ways of implementation. I think
that can improve a lot, can improve first of all inpatient facilities so that people would stop
stigmatizing against Mathare, so in terms of employing people, getting enough beds, getting drugs
and also subsidizing the medication. (Healthcare provider 6_Social worker)
The role of government in addressing the needs of persons with social disadvantages who also face
challenges of the health care and education that are critical for employment is also highlighted in
the statements of the study participants:
I think government has a very, very big role I mean for a long, long time health has been neglected in
low-resource or developing countries context; however you want to call it. The fact that the budget
is great on security and less on primary education or health in itself very telling and we need to
come up with institutional mechanisms to address poverty and socioeconomic disadvantages.
(Healthcare provider 9_Psychologist)
This statement is relevant because the healthcare providers identified self-employment as a useful
alternative to formal employment, which is scarce. Self-employment or self-help businesses offer
persons with mental disabilities the flexibility and control that is lacking in formal jobs.
…what I have noticed is that there are more of those who are self-employed than those who are
formally employed are basically again what we’ve seen that securing employment is not easy
for them so majority just choose to have some private business or something somewhere just to
employ themselves, yes. (Healthcare provider 1_Psychologist)
Achieving self-employment may be dependent on dependent on financial resources and
government social welfare programmes, because of the social disadvantages facing most persons
with mental illness from very early in life.
Hence, in the quantitative study, 9.1% of participants suggested formal education and training for
persons with mental disabilities as relevant to achieving greater employment.
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I think they have social protection factors like being educated, being employable because
of that educational training or skill that they have, often times is high level of management
positions so there is already some success and some sort of problems that they have learnt and
they are managing to the relationships or inciting in stress through psychotherapy and kind of
psychopharmacologies is not very difficult. (Healthcare provider 9_Psychologist)
9.4 Discussion
Our study is the first in Africa to explore the perspectives of mental healthcare providers
on employment of persons with mental disability. In Kenya, we identified mental illness, a
dysfunctional health system, social stigma, low socioeconomic status, and lack of government
or policy commitment as the major barriers to employment of persons with mental disabilities,
while public education on reducing stigma, improved mental health care and policy advocacy on
employment are some of the suggested facilitators of employment. In Nigeria, public education to
reduce stigma and improved health care were the highest reported facilitators of employment.
In identifying the pathways to employment for persons with mental disability we explored the
perspectives of healthcare providers on their employment. The majority of the study participants
identified the relevance of employment for persons with mental disabilities and its role in the
recovery process. The relevance of this finding has been previously recorded [33, 34]. Mental
healthcare providers who support employment for persons with mental illness in these settings
offer both care and psycho-education. It is, however, pertinent to note their observation that not
all persons with mental disabilities can work. We believe that this does not suggest a negative view
on the ability of persons with mental disability to work, but rather a declaration of the realities
of their perception of diverse abilities. This observation is relevant and needs to be taken into
consideration by programmes that promote employment so that a one-size-fits-all solution is not
adopted but considerations and relevant provisions made for those who may have different needs.
We explored the perceived barriers to employment and identified five clusters including
mental illness, dysfunctional health system, social stigma, low socioeconomic status, and lack
of government or policy commitment. Mental illness is a known barrier to employment and
its capacity to affect social and occupational functioning has been documented [15]. Our study
identified the dysfunctional health system as another barrier. The complexity and extent of the
problems in the health systems are wide and merit attention. The shortage of mental-health
professionals and lack of essential medication for mental health are pivotal for mental health
care [22, 35]. The challenges of healthcare financing and discriminatory practices of health
insurance companies compound the fate of persons with mental illness, particularly if they also
face socioeconomic challenges. The essential nature of effective health systems are evident in
the variations across countries depending on commitment to healthcare financing and effective
health care [36] and the lack of health insurance is associated with high unmet need for mental
health services [37]. The widespread social stigma that cuts across all social strata in this study
is another barrier. The fear and lack of information among employers enforces the stigma and
limits their employment of persons with mental disabilities [38]. The stigma borne by the family
Perspectives of mental healthcare providers on employment
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9
and other individuals deprives persons with mental disabilities of the health care they deserve;
and, sadly, healthcare workers with duties towards patients with a mental illness stigmatize them.
Stigma and discrimination thrive on cultural bias and ignorance and constitute a limitation to work
opportunities for persons with mental disabilities [3, 27, 39]. Studies have previously documented
the negative interaction between poverty and mental health the two-way relationship between
them [35, 40]. Another barrier to the employment of persons with mental disabilities identified
in this study is the lack of government or policy commitment to mental health care. This finding
perhaps ties up with addressing all the other barriers which the government as duty bearer ought
to remove. The observed challenges all obtain to low-income settings where governments have
abdicated their responsibilities to citizens [35, 36]. This developmental challenges strengthens the
social drift and all the associated difficulties persons with mental disabilities experience and the
attendant employment challenges [35, 41].
Our study has also offered pathways to improving the opportunities of employment for persons
with mental disabilities. The four characteristics of these pathways include information on stigma
reduction, better health care, policy advocacy in employment, and government commitment
to health care and social welfare. In order to address the ignorance and misinformation on
which stigma strives, there is need to address the problems of stigma. This might ensure that
employers better understand the ability of persons with mental disabilities to work and the need
to provide workplace support. It could also enhance social and family support for persons with
mental disabilities. Addressing stigma may also help in enhancing the quality of mental healthcare
services [7, 8, 26]. We believe that reduction of stigma may lead to the improved quality of mental
healthcare services, which in turn may change discriminatory insurance policies and effective
procurement of essential medicines in public hospitals and clinics. Studies have suggested that
institutionalized stigma in the health system affects access to and uptake of care [41, 42]. Our
study also suggests the implementation of policy advocacy on employment to improve employment
opportunities for persons with mental disabilities. This would ensure that mechanisms that guard
against discriminatory employment practices are in place and that dialogue and collaboration
with employers is used to achieve fair employment practices. There is evidence in support of this
finding and studies suggest that adoption of inclusive employment policies facilitates employment
for persons with disabilities [34, 43]. Lastly, in order to improve employment opportunities for
persons with mental disabilities, government commitment to health care and social welfare is
critical. Health care, education, and social welfare are human rights and when governments create
the environment in which they flourish, these enhance social participation and inclusion [23, 36,
44]. The importance of universal health coverage cannot be overemphasized and Goal 3 of the
Sustainable Development Goals (SDGs) supports an increase in health financing to ensure health
care for all [45]. This may be achieved when only when all governments improve health financing
and especially mental health care. Social welfare would ensure rehabilitation services and there is
evidence to suggest that cash transfers and loans may enhance self-employment for person with
disabilities in low-income settings [35].
Our study also identified some grey areas which were perceived as both barriers and facilitators of
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employment for persons with mental disabilities. Pre-employment assessment and disclosure were
seen as both barriers to and facilitators of employment. Although pre-employment assessment
provides information on the needs of an employee in terms of making reasonable accommodation,
it may also be a limitation to employment [2]. This observation has been made by studies and is a
vexed issue similar to perceptions about disclosure. The argument for disclosure of mental illness
to employers is that it would foster the provision of reasonable accommodation and is also relevant
to enable employers to access the tax rebates and benefits they obtain from the government for
employing persons with disabilities. Studies also suggest, however, that disclosure of mental
disability may end a job interview and lead to stigma at the workplace [2].
The strength of our study lies in its design; using both qualitative and quantitative methods
offered an opportunity to explore the observations of mental healthcare providers and their
contextual experiences. Collecting data from two lower middle-income countries (LMICs) such as
Kenya and Nigeria enabled us to understand the perspectives of mental health professionals in
these settings. The findings from the qualitative study were corroborated by the results of the
quantitative study and indicated the similarities in employment challenges faced by persons with
mental disabilities in LMICs contexts. Our study also has some limitations. The participants in the
qualitative study were purposively selected and may have introduced a form of selection bias that
affects the generalization of our study findings. Our efforts to include psychiatrists in the FGD
conducted in Kenya were unsuccessful, and only psychologists were finally included. The reports
of the healthcare providers involved in the quantitative study may also have been affected by recall
bias or social conformity. For logistical reasons, we were unable to conduct qualitative interviews
with mental health professionals in Nigeria. Therefore, a direct comparison of the results from
both countries is not possible, but both, Kenya and Nigeria are similar in terms of the unmet needs
for mental health care (MHGAP) and in this study both were used to elicit views on employment
of persons with mental illness in LMICs settings [30]. Also, we could not confirm the profession
of about 8.8% of the respondents who completed the online questionnaire. Nevertheless, we
included their reported information on the perspectives on employment of persons with mental
disabilities and on the barriers and facilitators to avoid selection bias.
9.5 Conclusion
Employment is a human right and crucial for the recovery of persons with mental disabilities. Mental
healthcare providers play a crucial role in the employment of persons with mental disabilities.
However, a complex interaction of factors limits employment opportunities for such persons. In Kenya,
the identified barriers to the employment of persons with mental disability include mental illness,
a dysfunctional health system, social stigma, low socioeconomic status, and lack of government or
policy commitment while public education on reducing stigma, better mental health care and policy
advocacy on employment are some of the suggested facilitators of employment. In Nigeria we found
that public education to reduce stigma and improved health care were the most reported facilitators
of work ability. These complex factors require multilevel approaches to untangle and address their
interconnectedness. An improved healthcare system and government commitment to mental
health care and social welfare are essential for the employment of persons with mental disability.
Perspectives of mental healthcare providers on employment
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9
Ethics approval and consent to participate
The study design was approved by the Amsterdam Public Health science committee (WC2017-
011). Maseno University Ethics Review committee (MSU/DRPI/MUERC/00391/17) Kenya and
Imo state University Teaching Hospital (IMSUTH/SC/121) Nigeria approved the study. Informed
consent was obtained from all study participants.
Consent for publication
Not applicable
Availability of data and material
Anonymized data are available upon request from researchers, who meet the criteria set out
in the Vrije Universiteit, Amsterdam data policy. Request for data may be made through the
corresponding author.
Competing interests
The authors declare no competing interests.
Funding
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium FPA 2013-0039 (SGA2016-1346).
Authors’ contributions
The study was designed by IDE and BJR. and reviewed with JFGB. IDE collected the data, analysed
and wrote the first draft with CA and MG. IDE, BJR, CA, JFGB and MG revised the manuscript and
approved the final version.
Acknowledgements
The authors are grateful to all the mental healthcare providers involved in the study. Mònica
Guxens is funded by a Miguel Servet fellowship (MS13/00054) awarded by the Spanish Institute
of Health Carlos III (Ministry of Economy and Competitiveness). ISGlobal is a member of
the CERCA Programme, Generalitat de Catalunya.
Prior presentation
Presented as a video abstract at the ISGlobal PhD Symposium, Barcelona in November, 2018.
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Published asEbuenyi I D, S. Rottenburg E, Bunders-Aelen JF, Regeer BJ. Challenges of inclusion: a qualitative
study exploring barriers and pathways to inclusion of persons with mental disabilities in technical
and vocational education and training programmes in East Africa. Disability and rehabilitation. 2018
Sep 22:1-9.
C H A P T E R 1 CHALLENGES OF INCLUSION:
A QUALITATIVE STUDY EXPLORING
BARRIERS AND PATHWAYS TO
INCLUSION OF PEOPLE MENTAL
WITH DISABILITY IN TECHNICAL AND
VOCATIONAL EDUCATION AND
TRAINING PROGRAMMES IN
EAST AFRICA
C H A P T E R 1 0
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10. CHALLENGES OF INCLUSION: A QUALITATIVE STUDY EXPLORING BARRIERS AND PATHWAYS TO INCLUSION OF PEOPLE MENTAL WITH DISABILITY IN TECHNICAL AND VOCATIONAL EDUCATION AND TRAINING PROGRAMMES IN EAST AFRICA Abstract
Purpose: To explore barriers and pathways to the inclusion of persons with mental and intellectual
disabilities in technical and vocational training programmes in four East African countries, in order
to pave the way to greater inclusion.
Materials and Method: An explorative, qualitative study including ten in-depth interviews and a
group discussion was conducted with coordinators of different programmes in four East African
countries. Two independent researchers coded the interviews inductively using Atlas.ti. The
underlying framework used is the culture, structure and practice model.
Results: Barriers and pathways to inclusion were found in the three interrelated components of
the model. They are mutually reinforcing and are thus not independent of one another. Barriers
regarding culture include negative attitudes towards persons with mental illnesses, structural
barriers relate to exclusion from primary school, rigid curricula and untrained teachers and unclear
policies. Culture and structure hence severely hinder a practice of including persons with mental
disabilities in technical and vocational education and training programmes. Pathways suggested
are aiming for a clearer policy, more flexible curricula, improved teacher training and more inclusive
attitudes.
Conclusion: In order to overcome the identified complex barriers, systemic changes are necessary.
Suggested pathways for programme coordinators serve as a starting point.
Key words: mental illness; disability; labour market inclusion; employability; vocational training;
East Africa.
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Implications for Rehabilitation
• Clear and up-to-date information on mental disability is required to engender societal
participation and especially stakeholders in technical and vocational education and training
programmes.
• Affirmative action and policy implementations of national and international human rights
legislations are required to address the challenges of enrolment in in technical and vocational
education and training programmes.
• Disability organisations and government should adopt a more open and strengths-based
attitude, tailor-made curricula, specific teacher training as well as clearer policies to ensure
better inclusion of persons with mental disabilities in technical and vocational education and
training programmes.
10.1 Introduction
Persons with disabilities face serious employment challenges, particularly in low and middle-
income countries (LMICs). As a response, a great number of projects and programmes have been
introduced aiming to enhance the chances of employment for persons with disabilities. Supported
employment, sheltered employment and Inclusive redesign of work processes, Technical
and Vocational Education and Training (TVET) are used worldwide to enhance employment
opportunities for persons with a disability [1-3]. TVET as a pathway to employment is supported
by most national legislation as well as the United Nations Convention on the Rights of Persons with
Disabilities (UNCRPD) [2, 4, 5]. Evidence of the value of TVET abound [6, 7]. For instance, in their
systematic review of TVET in LMICs, Tripney and Hombrados [7] report a positive association
between TVET and employment outcomes. The International Labour Organization (ILO) and
United Nations Educational, Scientific and Cultural Organization (UNESCO) recommend the
acquisition of vocational skills as a means to facilitate formal and informal employment for persons
with disabilities [8]. In addition, inclusive education is relevant to achieving the Sustainable
Development Goals (SDGs) 4 and 8 for education and work respectively [2, 9].
Despite being designed to focus on persons with all kinds of disabilities, it was found that only
a small number of programmes include persons with mental disabilities [2, 4, 10, 11]. Mental
illness, however, has been found to affect concentration, working memory, social interactions, and
working capacity, all of which constitute considerable employment hurdles [12-14]. Furthermore,
stigma and discrimination associated with mental illness affect the employment opportunities of
persons with such an illness [1, 2, 7, 15, 16]. It is assumed that persons with mental disabilities
would greatly benefit from participating in the programmes.
While the precise reasons and mechanisms of exclusion of persons with mental illness are yet
to be understood, the very definition of mental disability might be one of the key factors. Severe
mental illness is considered a disability in the international classification of Functioning, Disability
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and Health (ICF) [17]. Despite this categorisation, it has been found that persons with mental
illness and their communities often do not consider themselves as persons with disabilities [18-
20]. In a study of persons with mental illness, Thoits [20] characterized this attitude as a form of
identity deflection in order to resist stigma. This discrepancy may be a factor that explains why
programmes to enhance the inclusion of persons with mental disability have often not succeeded
as well as initiatives focusing on other disabilities.
There are also known and large cross-cultural differences in the understanding and perception
of mental illness: ‘culture is fundamental both to the course and the cause of psychopathology’
[21]. The ICF is based on the biopsychosocial understanding of mental illness, which defines it as a
disability; however, there are significant differences in explanations of mental illness in sub-Saharan
African countries [22]. Hence, persons with mental illness are often originally targeted in the design
of the programmes, as for example by Light for the World, which considers inclusive development
to encompass all people with disabilities, including those with mental illness. However, individuals
with a mental disability might still not benefit from the programmes as neither they themselves
nor their immediate environment perceive them as persons with disabilities. For this study mental
disability refers to either common or severe mental disorders that impairs an individual’s social
and occupational functioning [17, 23].
The aim of this study is to unravel the reasons and mechanisms behind the limited inclusion as
well as to identify pathways towards enhanced inclusion of persons with mental disabilities
in TVET programmes in East Africa. The findings are expected to inform policy makers and
non-government organisations (NGOs), and enhance the employment opportunities of
individuals with mental disabilities in the long run. Key words: mental illness; disability; labour
market inclusion; employability; vocational training; East Africa.
10.2 Theoretical Framework
A theoretical model was used in order to systematically analyse the data. The structure, culture
and practice model is applied here [24], and has been widely used in system theory to understand
the functioning of societal systems such as health systems [25]. This interaction between culture,
structure and practice is conceived as a possible enabler or constraint to functioning in social and
health systems [25]. Structure, culture and practice together form constellations that ‘both define
and fulfil a function in a larger societal system’ [24]. The practices of actors (what is being done)
are shaped by both the culture (the shared way of thinking) and the structure (the way things are
regulated). At the same time the practices, through the agency of the actors, influence both the
culture and the structure. Thus, between the three, there are recursive interactions (see Figure
10.1).
More concretely and adapted to the context of this study, practices include the way people act
towards persons with a mental or intellectual disability and their inclusion in (or exclusion from)
TVET programmes. The culture includes all thoughts, norms, values that actors in the context
attribute to persons with mental disability. Beliefs and practices relating to mental illness can lead
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to discrimination and hinder access to development programmes [26]. Finally, the structure entails
the laws and policies regarding people with mental disability, e.g. the admission requirements to
TVET programmes or the training of teachers.
These three concepts are not independent of one another, but, as depicted by the arrows in Figure
10.1, dynamically influence one another. Actors’ thoughts about people with mental disabilities are
shaped by and shape the policies and laws in place [27], and at the same time define the practices of
actors [26, 28]. The interactions with persons with mental disabilities, i.e. the practices, also shape
both the beliefs (i.e. the culture) and the regulations (i.e. the admission criteria and policies defining
who benefits and who does not). Barriers and pathways to the inclusion of persons with mental
disabilities in the TVET programmes are hence analysed along the three main concepts and their
intersections.
Introduction of the case
UNESCO defines TVET as ‘those aspects of the educational process involving, in addition to general
education, the study of technologies and related sciences and the acquisition of practical skills,
attitudes, understanding and knowledge relating to occupation in various sectors of economic life’
[29]. TVET is designed to achieve the right to education and inclusiveness for all persons, including
persons with disabilities [29]. TVET programmes are either public or private and are organised
by local governments, faith-based organisations, or NGOs. Disability-specific NGOs like Light
for the Word Netherlands in collaboration with local Disabled Persons Organisations (DPOs)
support TVET programmes so as to improves access to education and employment for persons
with disabilities. Light for the World Netherlands started the EmployAble programme through
which it works with TVET organisations in East Africa. In Kenya, TVET training is offered through
vocational institutions like Technobrain, Baraka Agricultural College and Kabete Technical Training
Institute [30]. A recent report of Light for the World, revealed that of 406 youths with disabilities
enrolled in TVET only 7% were found to be persons with mental/psychosocial disabilities [30].
Figure 10.1: Framework based on van Raak et al. [24]
229
Figure 1: Framework based on van Raak et al. [24]
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10.3 Methods
Design
A qualitative, exploratory study was conducted with TVET organisations in four East African
countries - Ethiopia, Kenya, Rwanda, and Uganda. The organisations in the countries were chosen
because of their collaboration with Light for the World Netherlands. The main method used was
semi-structured in-depth interviews conducted via Skype and face-to-face interviews in Kenya.
Purposive sampling was used to include participants who are TVET and DPO coordinators in
managerial positions and who were involved in the initial phase of the EmployAble programme in the
selected countries. They are assumed to be especially knowledgeable about the TVET recruitment
process and with years of work experience in the disability sector in their countries. All ten TVET
and DPO coordinators contacted (six men and four women) agreed to participate in the study.
They were five DPO coordinators and five TVET coordinators in Ethiopia, Kenya, Rwanda, and
Uganda. When no new themes or ideas emerged in the interviews and discussions with the study
participants, data saturation was reached and no further participants were invited to participate
in the study. A group discussion with participating TVET and DPO coordinators in Kenya was held
in order to validate findings. In addition, coordinators of mental health organisations were invited
and they provided insights on their conceptualisation of the difference between intellectual and
mental disabilities.
Data collection and analysis
Data collection took place between November 2016 and May 2017 as part of a formative research
process [31]. In the interviews, factors relating to the inclusion or exclusion of persons with mental
illnesses in TVET programmes were explored. The role and attitude of teachers, employers, families
and communities as well as policies and regulations were investigated. Data collection followed an
iterative process, with emerging issues from earlier interviews used to modify themes probed in
subsequent interviews.
IDE conducted eight interviews via Skype and two face-to-face follow-up interviews. The
discussions were conducted in English and lasted between 45 and 90 minutes. The audio
records were transcribed verbatim. Informed consent was obtained from all study participants
Observations and field notes made during visits to TVET sites and meetings with TVET providers
were also incorporated in the analysis.
The transcripts and field notes were imported into Atlas.ti software [32] and two independent
researchers, IDE and ESR, inductively coded the interviews. After the initial round of coding, over
twelve codes generated by the different researchers were compared and differences resolved
in discussion with the JFGB and BJR. Five common themes emerged, which informed the final
analysis.
Ethics
The study design was approved by the Amsterdam Public Health science committee (WC2017-
011). The Maseno University Ethics Review committee approved the study (MSU/DRPI/
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MUERC/00391/17).
10.4 Results
Barriers and pathways to the practice of inclusion of persons with mental disability were found to
relate to the underlying culture and structure, as well as their intersections. Before laying out the
barriers and pathways, we discuss what is understood as mental illness and disability.
Understanding mental disability
Beliefs about what mental illness entails and in how far it is considered a disability were
explored. While the UNCRPD makes a distinction between persons with mental and intellectual
impairments and physical and sensory impairments (UNCRPD, Article 1) [5] and understands both
as disabilities, most participants do not consider mental impairments as disabilities and also do not
always recognise mental health conditions as distinct from intellectual disability.
Study participants argued that mental illness is not a disability, because it is not necessarily a long-
term condition and because of its reversible character, either with medication or with the help of
psycho-social support.
Our organisation […] for mental disability actually categorises mental disability into two [...]:
mental illness and then there is […] madness. Madness […] require[s] medical attention. But people
with mental illness do not require so much of medical attention, they may need psychosocial
support, they may need family support and those could be actually reinstated. (DPO Coordinator
2_>5years experience)
So, depending on the severity of the mental disability, it is possible to rehabilitate people. She
further differentiates between mental and intellectual disability, saying ‘for the case of [my country]
we actually have an organisation working with intellectual disability and one working on mental health. So
they are different categories according to us’. (DPO Coordinator 2_>5years experience)
Another study participant highlighted the treatable character of mental illness, a differentiating
feature to intellectual disability.
[…] people with intellectual disability are often [...] people with a low intelligence quotient, […]
their understanding is impaired. Whereas those with mental illness are people with […] depression,
anxiety disorder, autistic disorder […]. If they are on their drugs, they are ok, but if they are not […],
that’s when their challenges are more obvious. (DPO Coordinator 1_>5years experience)
In spite of this difference, he merges the categories of mental illness and intellectual disability:
Generally, there is a lot of confusion when it comes to children, youths and adults with mental
disability. In other words, I term them as people with intellectual impairment. Don’t mind about
that. (DPO Coordinator 1_>5years experience)
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Two further study participants add to the complexity by making a distinction between a global and
a local definition of mental illness. One states ‘the global literature is saying [that] a mental health
condition is also [a] disability but for our case we don’t consider mental health conditions as […] disabilities’.
(DPO Coordinator 3_>5years experience). Another respondent comments along similar lines, ‘In
[my country], I don’t think mental illness is considered as a disability’ (TVET Coordinator 1_<5years
experience).
As this study was conducted in the context of the EmployAble programme, which groups together
mental/psychosocial impairments, including learning impairments (as distinct from visual, hearing
and physical impairments), we decided to include barriers and pathways regarding the inclusion
of people with intellectual and mental disabilities. Both groups were scarcely included in the
programmes so far, and the participants elaborated on the underlying reasons, which were to
some extent generic. Where possible and relevant, we explain the type of disabilities to which the
participants refer.
As mentioned earlier, only 7% of those enrolled in the TVET programmes in the context of
the EmployAble programme were people with mental/psychosocial impairments. In order to
understand the underlying mechanisms for this lack of inclusion (practice), we consider barriers
that were identified that reflect underlying norms and beliefs (culture) and barriers that pertain
to structures. Practices hence, conceptualised as the results as well as cause of both cultures and
structures, and are not analysed in a separate section, but within the sections on culture and structure.
Culture
The way mental illness is understood by society is reflected in the norms and beliefs that structure
the interactions with individuals with mental disabilities. The following section elaborates on
norms and actions taken towards individuals considered to have mental illnesses. First barriers
and then pathways are delineated.
Both teachers and employers were reported to be hesitant to include persons with mental
impairments. Two main underlying reasons emerged: first, a belief that persons with mental
disability are violent, which is prominent particularly in the school context; and second, that they
do not learn fast enough or are unproductive, an argument put forward by teachers and employers.
The following elaborates on these two sets of internalised beliefs.
One participant explains how mental illness is linked to violence. He asserts that:
[...] the attitude of people, not only the community but also the professionals; [...] towards these
people; because […] whenever they hear about the mental health conditions they think that these
people are kind of aggressive. […] whenever the case of mental health has been the focus […], the
discussion goes to the point at which this people could be violent. (DPO Coordinator 3_>5years
experience)
Another participant seems to have adopted this perspective, she states:
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‘But in most cases people with mental disability tend to reach the violent side. They tend to be
more talkative, more destructive and some of them actually reach an extent of being sick’. (DPO
Coordinator 2_>5years experience)
The second assumption is that person with mental or intellectual disability need a large amount
of support and learn too slowly. One participant states: ‘Because the thinking in people’s mind is that
these people can still not learn and if they learn they need a long time they need more support’ (DPO
Coordinator 2_>5years experience). They are also thought of as not needing to go to school or
needing to go to a special school as they cannot keep up with their classmates. One participant
summarised what, according to him, many would think:
… take him [a person with a mental illness] to somewhere maybe […] to […] some specialised
training institute […] like mat making or broom making, brush making’. He adds that these training
institutes are “not as such productive for the users to gain […] their livelihood”. (DPO Coordinator
3_>5years experience)
The study participants suggest that the slow learning of persons with intellectual disability is the
official explanation of sending them to special schools and excluding them from regular schools.
However, given the fact that persons with mental illness are thought of as being violent, segregating
people with and without mental illness might be an outcome that is, if not intended, welcomed by
many.
As elaborated upon by several participants, employers also assume that persons with mental
illnesses are not productive. One participant states: ‘Of course whenever we go with those students,
the employers start to say these are not productive’ (DPO Coordinator 4_>5years experience).
Another participant perceived employers’ insistence that students with mental illness are less
productive as obstructive. He stated, ‘employers don’t have the right attitude’ (TVET Coordinator
2_<5years experience).
A lack of understanding explains this assumption according to another participant: ‘So even in most
cases people do not [...] understand that someone with mental condition can be productive, [...] can be, like,
trained, employed, […] this is related with understanding’ (DPO Coordinator 3_>5years experience).
The biased perception of mental illness and its consequences for persons with mental disability
are also highlighted:
…if you say you have intellectual disability then they will say this is a slow performer; […], and
that kind of perception of course […] already lets people down. They don’t get a chance to really
explore their potentials or to offer what potentials they have. (DPO Coordinator 2_>5years
experience)
The role of parents is described as ambiguous, ranging from being over-protective to the degree
of denying their children their own rights to not being involved enough in the schooling of their
children.
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Regarding the over-protection, one participant mentions: ‘their family [of the persons with
mental disabilities], have stopped them to go outside the community’ (DPO Coordinator 4_>5years
experience). Another one adds: ‘Unlike other disabilities, parents tend to over-protect their children
with mental disability. They feel they are the ones that can provide better protection and in protecting
them, they […] are denying them their own human rights’ (DPO Coordinator 2_>5years experience).
Some families even prevent their children with mental illness from going to school. One participant
explains:
Based on my experience, many people with mental or intellectual disability once they are born
in a family they are not expected to go to school. […] Some have decided for them that they
cannot manage so in most cases they do not have a chance to go to school. (DPO Coordinator
2_>5years experience)
On the other hand, another participant states that some parents do not support their children
enough: ‘The other problem [is] the lack of cooperation with the parents. The parents send their children
with such kind of disability, they just leave you the student but there is no other follow up they do’ (DPO
Coordinator 2_>5years experience).
The beliefs and perceptions regarding mental illness were not only said to be common to employers,
teachers, families and communities but also to be internalised by the persons themselves.
According to one participant, mental disability constitutes a large part of the self-concept of
persons with mental disability. He describes how this can become problematic when the person
seeks employment:
… when we place some student, they actually […] carry their disability along. So when they reach
there, they really want to be seen as […] people with disabilities. Yet the employer is looking at you
as an employee [...] not as an employee with disabilities. So if you carry that ticket of disability then
in most cases, they end up failing. (DPO Coordinator 2_>5years experience)
Regarding the culture, mainly three pathways were suggested for how to increase the inclusion of
persons with mental illness.
In response to the negative attitudes hindering inclusion of persons with mental disabilities,
attitudinal changes among community members were described as pivotal. As a pathway, a
strengths-based approach is suggested, in order for persons with mental disabilities to find their
place in the labour market.
A participant mentioned that there is a need to better empower persons with mental disabilities
and that more expertise is needed regarding how to do this:
[…] We have limited expertise in the country, in terms of how to empower the individuals
with mental disability; from […] understanding them and knowing how to help them. (DPO
Coordinator1_>5years experience)
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Another participant adds:
[…] they can be included just like any other person. It’s more of finding what they are good at and
looking at what is out there in the market, and match them with what they can do, support them
on the job [so that] eventually [they can] earn a living like any other person.’. (DPO Coordinator
1_>5years experience)
Further, one participant suggested that the parents or guardians might also have an important role
in advancing the chances of their children by explaining to the teachers their child’s disabilities, and
advocating for their rights, to reduce stereotyping and discrimination:
So, if they explain to the teachers and say actually I live with this child at home, they are not
violent and you only need to understand them. Then teachers can begin to adjust their fears and
are able to accommodate them. (DPO Coordinator 2_>5years experience)
In conclusion, a bottom-up strategy is proposed, starting with changed practices by those
immediately involved, and supported by a wider expertise on mental illness and mental disability
and capacity on how to empower persons with mental disabilities.
Structure
The structure, i.e. regulations, laws and policies at the level of organisations as well as at the state
level, shaping and shaped by the culture and by practice, also present barriers and pathways. Rigid
TVET curricula and admission requirements, inadequate teaching skills and lack of specialist
support, as well as unclear school policies, are structural barriers to the inclusion of people with
mental disability that participants identified. Pathways include providing guidance for students,
adaptive curricula and clearer policies.
The first barrier relates to the admission to TVET programmes. Admission is regulated by specific
requirements, including primary school certificates. However, persons with mental disabilities
often do not possess the required qualifications. As one respondent explains:
If you’re going to start with lower level vocational training [i.e. TVET], at least you complete your
primary education. But many of them do not even complete the primary education. They are just
ignored at the start of their life. (DPO Coordinator 2_>5years experience)
This structural barrier relates to the belief that persons with mental illness do not need to go to
school and the practice of denying them access.
The second barrier concerns a reported misfit between the profiles of persons with mental
disabilities and TVET curricula. The TVET programme comprises formal education and not only
the acquisition of vocational skills. Participants observed some of the persons with mental illness
or intellectual disability to be unable to meet the requirements of the TVET programme. One
respondent pointed specifically to the inflexibility of the programme:
So, when it comes to public TVET, they are structured in such a way that students have to (go)
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through a curriculum that is not flexible. (DPO Coordinator 1_>5years experience)
This is also related to teachers’ fear of students with mental illness, which, according to one
participant, explains why there have not yet been any curriculum adaptations. He states:
Then the teachers fear them, they feel they cannot really teach them, so there has not been
curriculum modification for them to fit in the mainstream training. (DPO Coordinator
2_>5years experience)
A further structural barrier is that teachers are often ill-equipped to deal with students with
mental disability. A lack of teacher training as well as specialist advice was mentioned numerous
times. One respondent pointed out that teachers are not used to teaching this group of people:
Teachers are not trained for that kind of mental disability. They normally always teach people
without disability and when you are including people with disability they cannot go on the same
rate of teaching. (TVET Coordinator 2_<5years experience)
The fact that TVET coordinators in many cases do not consider mental illnesses as disability
constitutes the fourth structural barrier. An underlying reason has been found to be policies that
are unclear regarding inclusion in TVET programmes. One respondent elaborates:
For us, the policy does not specify which kind of disability, they say disability in general, not […] the
visual, or mental or hearing. No, the policy says only inclusive education for people with disabilities
in general, they don’t specify intellectual or learning disability. This is why the policy is not detailed,
[…], not specifying the category of disability. (DPO Coordinator 4_>5years experience)
Regarding the structure, there were multiple proposals for how to overcome the barriers
mentioned. Participants suggested how to determine a better fit between the individuals and the
programmes offered and suggested several pathways towards inclusion. As one said, choosing the
right programme is essential:
[...] So better to look for, at least to know, the kind of training that people with disability, mental
disability can take. And the others cannot be attended by them. (TVET Coordinator 2_<5years
experience)
A study participant suggested it would be advantageous to make the curricula more flexible:
… you assess an individual, find out what this individual is interested in and instead of going
through a full curriculum maybe tailor-make a curriculum specifically for specific groups of people.
[…] Where individuals like those with mental disability could be accommodated in TVET and be
trained in a specific line of activity that they are interested in, and excel easily. (DPO Coordinator
1_>5years experience)
In order to find a good fit, several participants proposed that there should be specific advisers within
the programmes, some of whom had already been put that in place. One respondent explains:
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10
Now, there is a career guidance given to the students before coming, before starting their training
but […] at the time when we start[ed] this program [EmployAble], this kind of career guidance was
not present. (DPO Coordinator 4_>5years experience)
Similarly, another respondent described a ‘guiding and counselling centre’:
But under the EmployAble programme we’ve actually gone ahead especially in [my country] to
establish an inclusive kind of guidance and counselling centre. We have tried to empower the
counsellor […] to be able to actually take care of the students’ problems, including disability
related. (DPO Coordinator 2_>5years experience)
Teacher training is addressed as a pathway by several of the participants. One explained how
specific teacher training could advance inclusion:
You really need to prepare them [the teachers] and have people who already have the skills to
work with them [students with intellectual disability] to make them […] know that it’s possible,
that these students can also learn. (DPO Coordinator 2_>5years experience)
As another pathway towards better inclusion of persons with mental disability, a respondent
proposed is a clear policy regulating who is eligible for participation in the programme. He states,
‘…if the laws can be specific on what they are talking about, I think that can also help the implementers
to be guided on what exactly they need to do (DPO Coordinator 3_>5years experience). The last
suggestion, again, refers back to the very definition of mental illness and the understanding of what
it entails.
10.5 Discussion
This study was undertaken to explore the barriers and pathways to including persons with mental
illness and intellectual disability in TVET programmes in four East African countries. We found that
beliefs and attitudes form a culture of exclusion and segregation that is reflected in practices, such
as not sending persons with mental disabilities to school or not employing them. Structural hurdles
reinforce both the culture and the practice, e.g. TVET admission criteria that persons with mental
disabilities often cannot meet and policies that do not clearly label mental illness and intellectual
disability as a disability. As pathways, a more open and strengths-based attitude, tailor-made
curricula, specific teacher training as well as clearer policies have been suggested.
The exclusion of persons with mental illness or intellectual disability cannot be reduced to a
handful of independent causes that could be addressed directly. Rather, a complex net of factors
influencing each other has been found to explain the exclusion. This has consequences for how
best to tackle the problem.
The barriers identified here are entangled, complex and persistent. Schuitmaker [33] argues that
problems are persistent when attempts to solve them are ‘worked against by features embedded in
the […] system itself’. Persistent problems are produced and reproduced by the agents who shape
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and are shaped by culture and structure. As has been shown, the current culture and the structure
are seriously hampering practices of inclusion of persons with mental illness or intellectual
disability into TVET programmes.
In order to tackle persistent problems, simple solutions focusing only on one aspect are bound to
fail [34]. A system perspective is needed to envisage a way forward, in which multiple pathways
are followed simultaneously and at different levels, mutually supporting each other. Changes in
practice will induce changes in culture (albeit at the local level initially) and changes in policy will
support changes in practice.
Based on the findings of this study, different pathways were identified that would support the
inclusion of people with mental disability in TVET and hence support their employability (see
Figure 10.2). Suggestions for the practice of TVET providers are to acquire expertise on mental
disability; to acquire expertise on a strength-based approach to guiding students; to adjust training
programmes to the needs of students; to support students through career guidance; and to match
students’ individual capabilities with the needs of potential employers. Putting these suggestions
into practice is expected to empower individuals and enable them to earn their living. Empowered
individuals and changed practices together represent a belief in people with mental disabilities as
unique individuals with diverse capacities and signifies a change away from a culture of stigmatising
people with mental disabilities as a group and regarding them as violent and unproductive. Policies
will not only support the required changes in practice of current front-runners, but also stimulate
others to follow suit, which, in turn, will affect the underlying system of beliefs towards a culture
that is more conducive to disability-inclusive development.
The pathways are intertwined and there is no clear starting point nor a central steering power. Also
systems are relatively resistant to change, as they reproduce themselves and the structures that
constrain them [25]. From a system-innovation perspective, it is recommended to start where the
energy is, with people who are willing to divert from the mainstream and dare to take risks [35].
Even when policies are not conducive, professionals can find the room to manoeuvre and employ
rule flexibility, for instance to adjust training programmes to the needs of the students with mental
disabilities [35].
Individuals with mental disability are unique and possess skill sets that that are useful for their
wellbeing and society at large [5]. This understanding underpins the inclusive development
movement and global efforts at inclusion [36]. Disability-specific NGOs have a unique role to play
as change agents to demonstrate that policies can be supported, not only by national policy, but
also by NGOs [37].
Understanding mental disability
An increased understanding of mental disability is pivotal to the various pathways. In this study,
participants perceive intellectual disability as the same as mental disability. This classification is
essential for persons with mental illness because it also affects their opportunities of employment
and inclusion in TVET program; especially in climes where person with intellectual disability are
Challenges of inclusion
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10
tagged slow learners and excluded from educational endeavors by persons without the relevant
skill to teach them. Clear and precise definition of mental illness and definition of what constitutes
mental disability has been a source of controversy [38]. The pertinent lesson to note is that
inaccurate and poor understanding boosts stigma and poor attitude towards persons with mental
illness [28, 39-41]. In a recent position paper issued by Users and Survivors of Psychiatry, Kenya,
the authors urge policy makers to note the difference between mental illness and intellectual
disability and avoid lumping both forms of disability together and making developmental plans
difficult [15]. At the same time, it has been argued that it is not as much the classification that
is important, but the functional impairments that may have resulted from the mental illness or
intellectual disability [17]. Hence, educational institutions and employers need tools and human
resources to assess at individual level functional impairments in relation to requirements of the
profession they aspire, in order to be able to make reasonable accommodation.
Moreover, whereas theoretical paradigms have explicitly offered a multifaceted notion of
disability, the social perceptions of disability have not accommodated persons with mental illness
[26, 42, 43]. At the same time, although mental illness is included as a disability in the UNCRPD,
many, including persons with mental disabilities themselves, do not recognise it as such and do not
230
Figure 2. Suggested recommendations for the practice of TVET providers and associated changes in structure and culture
Figure 10.2: Suggested recommendations for the practice of TVET providers and associated changes in structure and culture
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necessarily support it as it adds another layer of stigma [18]. This dilemma, and that of disclosure
to enable reasonable accommodation versus concealment and not being able to offer the right to
adjustments [44], will need to be debated more within the communities of persons with mental
disabilities. This might also be a task for disability-specific NGOs and mental health organisations.
10.6 Limitations
It is pertinent to state that the small sample size of the participants limits the generalization of the
findings that rely on expert opinion from TVET and DPO coordinators. Their observations reflect
their lived experiences in their particular setting and are subject to their personal interpretations.
For a more complete assessment of the situation, it would have been advantageous to include
other groups of stakeholders, including TVET teachers, students with mental disability, community
members, and policy makers.
10.7 Conclusion
Persons with mental illness or intellectual disability are largely excluded from TVET programmes
and multiple underlying reasons have been identified. Most prominent are an attitude that
legitimises exclusion from school and the labour market and policies that do not understand mental
illness as a disability. Pathways suggested by participants are far-reaching and encompass diverse
areas including attitudinal changes, adaptive curricula and inclusive policies. These have been
found to affect the culture and the structure and would be manifested in practices. For example,
formulating an inclusive policy will probably change the admission criteria to TVET programmes
and even the way for increased participation. At the same time, this would influence people’s
perception of what mental illness entails and most likely also their attitude towards it and thus
the direct interactions. If efforts are focused on culture and structure as underlying issues, they
have the potential to induce system-wide change. Suggestions made by the coordinators of TVET
and DPOs in the four East African countries are to be further clarified and implemented in the
near future in order to enhance the chances of employment of persons with mental illness or
intellectual disability.
Authors contribution
Authors IDE, JFGB and BJR were involved in the design of the study. IDE conducted the data
collection while IDE, ESR, JFGB and BJR were involved in data analysis. All the authors were
involved in the drafting and approval of the final manuscript.
Acknowledgement
We are grateful to Light for the World Netherlands for their support in this study and to all the
study participants and theirs organizations in East Africa. We also thank the anonymous reviewers
of the manuscript and Prof. dr. Jacqueline Broerse for reviewing the initial draft..
Funding
This work was supported by funding received by the first author from the Erasmus Mundus Joint
Doctorate (EMJD) Fellowship-TransGlobal Health Consortium 2013-0039.
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10
Declaration of interest
The authors declare no conflict of interest.
Prior presentation
Presented as an abstract at the TransGlobal Health Annual Meeting, September 2017 (Amsterdam,
The Netherlands)
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NoteThis chapter presents a concise account of the study dissemination event which can be considered
the start of phase 3 ; action planning and implementation.
C H A P T E R 1 1 STAKEHOLDER REFLECTION
ON THE RESULTS
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11. STAKEHOLDER REFLECTION ON THE RESULTSThe critical role of research in identifying pathways to change in health care is commonly
acknowledged [1, 2]. Health research is important not only for generating health knowledge and
improving care, but also for providing crucial information about the nature and everyday reality
of health care to stakeholders and policy-makers. In health research, working with the community
or stakeholders is considered significant in addressing health challenges and also bridging the
research–practice gap [3]. However, sometimes research is conducted without due consultation
with stakeholders, leading to results that lack the experiences of local actors. Also, sometimes
research is conducted but not shared with the stakeholders, so that the relevant stakeholders
are unable to use the research findings. This is common in research on vulnerable groups such as
persons with disabilities. Sharing the findings with stakeholders offers better perspectives on the
problem.
Our study was designed to identify factors influencing employability for persons with mental
disability. We undertook a literature review, a policy review of relevant documents and multi-
stakeholder mixed methods studies to understand the barriers to and facilitators of employability
for persons with mental disabilities in Kenya.
In this reflection, our aim was to present the findings from the previous phases of the study to the
stakeholders who participated, in order to test the validity, utility and continued relevance of the
findings. To what extent are the identified pathways to improved employability relevant in practice?
What areas for improvement and future research are there? We thus organised a dissemination
meeting, to share the findings with the stakeholders, and to understand their perspectives on the
pathways to employability for persons with mental disabilities in Kenya. In the following sections,
we present 1) a background of the findings from the initial phases of the study, 2) the outcomes of
the dissemination event, and 3) a reflection on the outcomes.
11.1 Findings from the initial phases
The previous phases of our study entailed in the first phase, a literature and policy review, and in the
second phase, a multiple stakeholder study using both qualitative and quantitative methods. We
sought to explore factors influencing employment of persons with mental disability in Kenya. First,
our literature review (Chapter 5) indicated that across Africa, a combination of factors including
social stigma and discrimination, psychiatric illness, and lack of social support and government
welfare programmes, were the major barriers to employment for persons with mental illness.
Our findings indicated that in Kenya there is heightened stigma against mental illness and very
little access to state support for persons with mental disability (Chapter 7). As a result, individuals
with mental illness depend on their family members for socio-economic support and survival. Our
study on stigma and employment, indicated that 69.7% and 56.3% of respondents experienced
discrimination in their workplace, or with retaining their job respectively. The findings also showed
Stakeholder reflection on the results
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that anticipated discrimination stopped 59.2% and 40.8% from looking for work or studying
(Chapter 8).
Second, disabled persons’ organisations (DPOs) are pivotal to the welfare of persons with
disabilities, although persons with mental illness are often left out or not recognised in most DPOs’
programmes (Chapter 10). This omission often affects their inclusion in development programmes
for persons with disabilities. Family members share in their relative’s suffering and challenges,
especially in settings with significant stigma against metal illness. Yet, in their bid to shield their
relative with mental disability, they unwittingly become part of the cultural and structural barriers
to inclusive employment and education (Chapter 10). Similarly, mental health support NGOs and
groups provide information and the much-needed social network to affected individuals who
might otherwise be at a loss because of severe and disabling mental illness (Chapter 6).
Third, the role of employers in the employment of persons with mental disabilities is pivotal, and
better understanding among employers results in greater work opportunities and experience
(Chapter 8). However, in our study with employers, we found that only 15.2% have ever employed
person with mental illness, and that majority were unaware of the ability of persons with mental
illness to work. Although the Kenya Disability Act made provisions for 25% tax rebates for
employers of persons with disabilities, the employers were unaware of it, and to date none has
ever applied for this scheme (Chapter 8). It was clear that some employers required help and
information on how to provide reasonable accommodation in the workplace and the absence
of programmes for vocational rehabilitation or job coaching was suggested as likely barrier to
employment (Chapter 8).
Fourth, mental health care providers are responsible for meeting the health needs of persons
with mental disabilities. They play an important role in ensuring their ability to work by providing
optimal health care and maintaining the health–work environment. However, they suggested
that limited access to mental health care because of discriminatory insurance services and lack of
essential psychiatric medications are indirectly affecting the employability of persons with mental
illness in Kenya (Chapter 9).
Fifth, policy-makers play an important part in ensuring that policy and legal recommendations that
ensure reasonable accommodation in education, health and other spheres of life are available to
persons with mental disabilities. However, our review of policy documents in relation to the right
to work revealed a gap between policy provisions and practice in Kenya and other East African
counties. Although Kenya has ratified the CRPD, the use of derogatory remarks in their reference
to mental illness in national laws can be identified as a possible contributor to limiting employment
for affected individuals (Chapter 5). Our findings on lived experiences of persons with mental
illness showed that most were unable or unwilling to obtain a disability certificate that would allow
them to access government benefits (Chapter 6).
In spite of the findings from the literature and the stakeholder study, we lacked the answers on
the mechanisms of the identified problems and how they related to each other. Hence, in the
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dissemination meeting, we set out to share the findings with the stakeholders, and to work with
them to identify the pathways to employability for persons with mental disabilities in Kenya using
a stakeholder meeting approach.
Set-up of the Dissemination and Dialogue Meeting
This dissemination meeting which took place in October 2018 in Nairobi used roundtable
discussions to identify the pathways to improved employability for persons with a mental disability
in Kenya. Following a presentation of the results from the previous phases of the study, four key
questions were raised:
1. How can we motivate employers/organisations to access the tax rebates available for them
under the Kenya Disability Act?
2. What measures can we institute to ensure that government benefits for persons with
disabilities reach persons with mental disabilities?
3. What strategies would help to enhance job coaching or support for persons with mental
disabilities in the workplace?
4. How can we improve access to health care (e.g. through provision of essential and effective
psychiatric medicines, non-discriminatory insurance programmes) for persons with mental
disability?
Each of these questions represents what we might call a grey area in the field of mental health
care and employment for persons with mental illness in Kenya. Our findings may have stated, for
instance, that employers/organisations need to be motivated to access tax rebates under the Kenya
Disability Act; or that steps must be taken to ensure that government benefits reach persons with
mental disabilities. However, putting our findings into practice is a far more complex matter. To
bring our research to a close, we wanted to know what the stakeholders had to say.
All the stakeholders from the initial phase were invited for a dissemination and roundtable
discussion to respond and also to suggest potential solutions to the questions. Persons with mental
disability and their family members were invited through Users and Survivors of Psychiatry (USP)
Kenya and African Mental Health Foundation (AMHF), Kenya; mental health care providers were
invited from the University of Nairobi Kenya; persons from mental health and disabled persons’
organisations (DPOs) were invited from their national network; and policy-makers were invited
through referrals and recommendations of participants from the second phase of the study.
The majority of participants were women (62.3%) and had university-level education (89.1%). The
high level of education of the study participants may be related to the setting in Nairobi. All the
stakeholder groups participated in the meeting (Table 11.1).
The study findings of the first and second phase of the study were presented for an hour, after
which the participants responded through answers and comments. Subsequently, the participants
Stakeholder reflection on the results
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were randomly divided into four groups in order to create heterogeneous groups. Each group was
led by a trained research assistant to discuss each of the questions for 30 minutes; the groups
nominated a leader to present their collective responses. Participants from the other three groups
commented on their presentations and asked questions of their own.
11.2 Outcomes of the dissemination meeting
In this section, we present the participants’ responses to the grey areas identified in the initial
phases of the study.
Addressing the grey areas
Findings from the first and second phases of the study indicated the dearth of research on
employment for persons with mental illness, and an acute lack of political will in Africa to provide
social welfare schemes to ensure enjoyment of the rights to health and employment by persons
with mental illness. We also noted the non-acceptance of mental illness as source of disability, and
discussed the controversy this generated for the affected individuals, NGOs that are supposed to
help them as well as employers that ought to employ them. In Kenya, cultural and structural factors
reinforce negative attitudes towards and stigma against mental illness, which affect employment
opportunities for persons with mental illness. The majority of employers are unaware of the ability
of affected individuals to work, but were nevertheless willing to learn. The overwhelming social
exclusion faced by persons with mental illness compelled the majority to opt for self-employment
to avoid discrimination and also be in control of their own lives.
Given the problem analysis of these findings, the four areas (stated above) were developed
through discussion by the researchers and in consultation with stakeholders from the second
phase of the study. Stakeholders in the dissemination meeting expressed their agreement with the
study findings and considered the dissemination meeting relevant in identifying a useful pathway
to improved employability for persons with mental disabilities. Stakeholders provided answers and
suggestions on how to tackle the four grey areas presented during the meeting. The responses are
discussed in the following sections.
238
Table 1: Socio-demographic of meeting participants (N=55)
Variable Category N (%)
Sex Men Women
18 (32.7) 37 (62.3)
Educational level Secondary and below University and above
6 (10.9) 49 (89.1)
Stakeholder category Person with mental disabilities Family caregiver NGO worker Employer Health care provider Policy-maker Other
11 (20.0) 5 (9.1) 15 (27.3) 5 (9.1) 9 (16.4) 6 (10.9) 4 (7.3)
Table 11.1: Socio-demographic of meeting participants (N=55)
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216
1. Motivating employers/organisations to access tax rebates in Kenya
In the second phase, we thought that employers and organisations may be encouraged to apply
for the tax rebates available to employers of persons with mental disabilities and thus indirectly
increase the likelihood of offering them employment. However, in this reflection, the stakeholders
who participated in this group session noted that while this may be a useful pathway to change, it
was not perceived as such, but rather as a complex option that would require clear guidelines for
implementation. They suggested that information on the benefits of the tax rebates needs to be
shared with employers and clear instructions provided on the application process by the Kenyan
revenue authority, in order to avoid bottlenecks associated with the application. From the national
disability law, it is not clear what the application process entails and how employers can proceed
with it. One participant in the discussion stated:
…for me, guidelines in terms of how we implement this are very, very important. Because even
when you are trying to employ persons with disability, there is a cost implication in trying to
modify and adjust the environment. And we always say sometimes the organisation is too small
and they can’t afford it. (Group_1)
The participants also felt that although the idea of the tax rebates was commendable it may not
work for small companies. This may be related to a number of factors such as the fear of subjecting
their operations to scrutiny by the national tax authority, the bureaucracy associated with the
process, or the worry that the tax rebates may not be worth the effort.
2. Ensuring that government benefits reach persons with mental disabilities
During the first phase, we found that government benefits for persons with disabilities in Kenya
often do not reach persons with mental illness despite the recognition of mental illness as a
disability in the CRPD. We hypothesised that if government benefits such as small loans and grants
were to reach persons with mental illness, it may enable them to engage in self-employment or
small businesses.
However, in the dissemination, the stakeholders in the second group agreed that this may be
helpful but suggested that the underlying problem with uptake of government benefits by persons
with mental disabilities needed to be tackled first. They identified stigma against mental illness,
non-acceptance of mental illness as a disability by society and by persons with physical disabilities,
and the bureaucratic red tape as factors that make acquisition of a disability certificate difficult for
persons with mental disabilities. In order to solve this problem, one stakeholder suggested that
addressing the difficulty in obtaining the disability certificate would be helpful:
What can we do to ensure that that process is reduced from that six months to two three months
because it’s also if you may want to get a certificate, but that time will discourage you. (Group_2)
Another participant provided insight on the need for information on the government benefits for
both persons with mental illness and those in charge of administering them.
Stakeholder reflection on the results
217
11
[For] government opportunities, I immediately think of things like AGPO [Access to Government
Procurement Opportunities] […] what I hear especially with people who have mental health
disabilities they don’t know that those things exist; even when they are told that they are there,
the people who are in charge of those offices in the communities have never dealt with people with
mental health issues.. When they go to access them, they are turned away. They are told this is
not for you. (Group_2)
3. Using job coaching and support for persons with mental disabilities in the workplace
In the initial phase of the present study, we observed that some persons with mental disability
lacked job skills and experience owing to factors such as interrupted education, recurring
mental illness, and lack of support in the workplace. Employers also suggested that they
needed information on how to provide such support for persons with mental illness in the
workplace. In the dissemination meeting, stakeholders in the third group agreed that in order
to ensure inclusive employment for persons with mental disabilities, proactive measures to
ensure job coaching would be relevant in and outside the workplace. The peculiar nature
of mental illness creates a work identity crisis which affects the willingness to work and the
capacity to retain a job. In order to overcome this limitation, it was suggested that NGOs
and employers should promote job coaching and inclusive work processes. However, they
suggested that the limitation to achieving this depended on the disclosure of mental illness,
which is a precondition for effective job coaching and support in the workplace:
You see, to answer that question, disclosure will be important and also acceptance on the
employer’s side could, so that they can understand each other and they know how to handle the
weaknesses [challenges] of the individual. (Group_3)
This was a welcome point with which the participants identified, but they also noted that in order
to promote disclosure, it was essential to work on attitudes to mental illness to prevent negative
reception or reactions to disclosure.
I think it would be good to make legislation. If you look at the workplace environments, each
employer ideally should have a well-functioning mental health awareness program within the
work place ….but this does not exist and increases danger of disclosure. Because you might be
disclosing to people who don’t even know what exactly you are disclosing about, because most
people are not aware and don’t know about mental illness as a disability. (Group_3)
4. Improving access to health care for persons with mental disabilities
Mental health care is vital for the ability to work. In Kenya, the mental health system is affected by
the widespread shortage of human and financial resources for mental health. Mental health care is
neglected and there is little access to mental health services. Out-of-pocket spending remains the
main source of financing for mental health care. This is grossly limited because of the associated
poverty and lack of income faced by persons with mental disability. In the dissemination meeting,
stakeholders suggested that policy-level actions that ensure free/subsidised national health
CHAPTER 11
218
244
Tab
le 2
: Sta
keh
old
er R
esp
on
ses
Gro
up
A
dd
itio
nal
su
gges
tio
ns
fro
m t
he
gro
up
dis
cuss
ion
s
Ho
w c
an w
e m
oti
vate
em
plo
yers
/org
anis
atio
ns
to a
cces
s th
e ta
x re
bat
es a
vaila
ble
fo
r th
em
un
der
th
e K
enya
Dis
abili
ty A
ct?
D
evel
op
clea
r gu
idel
ines
to
imp
lem
ent
tax
exem
ptio
n
En
forc
e m
ech
anis
ms
for
com
plia
nce
Con
du
ct r
esea
rch
to s
up
po
rt e
vid
ence
on
tax
exe
mp
tio
ns
for
pers
on
s w
ith
dis
abili
ties
Cre
ate
ince
nti
ves
for
perf
orm
ing
org
anis
atio
ns
Sh
are
sto
ries
ab
ou
t ta
x ex
emp
tio
n
Wh
at m
easu
res
can
we
inst
itu
te t
o e
nsu
re t
hat
go
vern
men
t b
enef
its
for
per
son
s w
ith
d
isab
iliti
es
reac
hes
pe
rso
ns
wit
h
men
tal
dis
abili
ties
?
E
nsu
re fu
nds
rea
ch p
erso
ns
wit
h m
enta
l dis
abili
ties
rat
her
than
on
ly t
ho
se w
ith
ph
ysic
al d
isab
iliti
es
Q
uic
ken
the
pro
cess
of d
isab
ility
cer
tifi
cati
on
an
d a
cces
s to
insu
ran
ce
Su
bsi
dis
e co
st o
f tre
atm
ent
and
med
icin
es
In
clu
de
men
tal i
llnes
s in
insu
ran
ce p
olic
ies
(psy
chia
tric
issu
es)
Wh
at s
trat
egie
s w
ou
ld h
elp
to e
nh
ance
jo
b
coac
hin
g o
r su
ppo
rt f
or
per
son
s w
ith
men
tal
dis
abili
ties
in t
he
wo
rkp
lace
?
A
ddre
ssin
g d
iscl
osu
re a
nd
acc
epta
nce
issu
es a
t th
e w
ork
pla
ce m
ainl
y th
rou
gh:
C
lear
def
init
ion
of p
olic
ies
and
pra
ctic
es –
bo
th fo
rmal
an
d in
form
al
A
ddre
ssin
g th
e cu
ltu
re a
t w
ork
an
d t
he w
ork
env
iro
nm
ent
to p
rom
ote
on
e o
f em
pat
hy
and
a h
um
anis
ed o
ne
C
reat
ion
of i
nte
grat
ed w
ell-
bei
ng
pro
gram
mes
at
the
wo
rkp
lace
tha
t in
clu
de
men
tal d
isab
iliti
es a
nd
cre
ate
wel
l-b
ein
g co
mm
itte
es
Ho
w c
an w
e im
pro
ve a
cces
s to
hea
lth
car
e (e
.g.
thro
ugh
pro
visi
on
of
esse
nti
al a
nd
eff
ecti
ve
psy
chia
tric
m
edic
ines
, n
on
-dis
crim
inat
ory
in
sura
nce
p
rogr
amm
es)
for
per
son
s w
ith
m
enta
l dis
abili
ty?
N
HIF
-med
ical
dis
abili
ty p
acka
ges
(fre
e o
r su
bsi
dise
d)
E
nsu
re a
cces
s fr
om
an
y h
osp
ital
Adv
oca
te fo
r h
ighe
r ca
ps
wit
h s
ervi
ces
in m
ind
Im
pro
ve a
cces
s to
med
icin
es in
th
e co
un
try
– a
cco
un
tab
ility
(po
licy
to p
ract
ice
[dir
ecto
r o
f med
icin
es s
ervi
ces]
)
Tra
in a
nd
em
plo
y go
vern
men
t ps
ychi
atri
c st
aff
Se
nsi
tisa
tio
n t
o fi
ght
stig
ma
to e
nco
ura
ge in
div
idu
als
and
co
mm
uni
ties
Adv
oca
te fo
r af
ford
able
ess
enti
al m
edic
ines
Adv
oca
te fo
r re
pre
sent
atio
n t
o pu
sh o
ur
polic
ies
in a
cces
s to
med
icin
es
C
olla
bo
rati
on
(syn
ergy
) bet
wee
n m
enta
l hea
lth
su
ppo
rt g
rou
ps
and
men
tal h
ealt
h c
are
pro
vid
ers
Tab
le 1
1.2
: Sta
keh
old
er R
espo
nse
s
Stakeholder reflection on the results
219
11
insurance for persons with mental disabilities is non-negotiable in order to ensure their access to
employment. In order to highlight the problems one participant stated:
The NHIF [National Hospital Insurance Fund] is limited. You have to choose one hospital; one
brand of a hospital. If you have chosen [name of a hospital] and it doesn’t offer mental health, do
you know you will not be given any medicine? They will not give you anything. (FGD group_4)
Instead of providing definitive answers, the stakeholder responses raised more questions: who
provides guidelines on the application of tax rebates? Would the tax rebates be useful to informal
employers that form the bulk of employers in the country? How can one address the challenges
associated with obtaining a disability certificate? How to address the dilemma of disclosure? How
to make mental health care accessible and inclusive? They did, however, offer an opportunity to
understand better the many facets of the problem from the perspectives of the stakeholders. Table
11.2 enumerates additional suggestions of the stakeholders on the grey areas.
11.3 Reflection
This dissemination meeting with stakeholders aimed to identify the pathways to improve the
employability of persons with mental disability. The design sought to test the feasibility of the initial
study findings through a discussion with stakeholders. It offered us an opportunity to evaluate
how actionable some of the results from both the analytical and empirical studies were. What we
documented in this study is both interesting and revealing.
Although the literature and empirical study informed us that tax rebates may motivate employers
to employ persons with mental disabilities, we understand now that this is not a straightforward
pathway to improved employability for persons with mental disabilities. We know that it may
not be feasible for small companies or business owners who may be unwilling to undertake the
bureaucratic process involved or subject their business to scrutiny from tax authorities. Obtaining
tax rebates would also depend on employees with mental disability who have surmounted the
rigorous process of obtaining a disability certificate, as the odds are stacked against mental
disability in comparison to other sources of disabilities. Mental illness is indeed an illness that has
to fight for appropriate description, as Dumit observes in his seminal article on mental illness [4].
The fight and struggle to prove that one fits into the bureaucratic categories also takes for granted
the challenge affected individuals have to confront to accept disclosure.
The dilemma of disclosure in mental illness has been the subject of several studies, but there are as
yet no perfect answers or ways to predict reactions to disclosure of mental illness [5, 6]. It is a leap
of faith that persons with mental disabilities have to take in a society where even legal documents
reinforce stigma. Therefore, even with the ratification of the CRPD, we understand from this
study that government legislation alone may not end stigma, although it is an important step. It
is also required that the actions of all individuals ensure that inclusive employment for persons
with mental disability is realised. But before we achieve inclusive employment for persons with
mental disabilities, there are several interrelated preconditions such as: 1) that mental health
care providers ensure clinical stability; 2) willingness of persons with mental disability to obtain
CHAPTER 11
220
the disability certificate and disclose their diagnosis to prospective employers; 3) that employers
understand the ability of persons with mental disability to work; 4) government willingness
to support persons with mental disability; 5) that persons with mental disability wish to work;
6) that available mental health care works for persons with mental disability and 7) that social
stigma declines and understanding about mental illness improves. Finally, what warrants further
discussion is the role of poverty and socioeconomic status in all these factors.
That poverty has the ability to worsen the effects of disability is nothing new [7, 8]. Where state
resources are sparse, it may be difficult to meet individual needs in terms of health care and social
benefits. Our study indicates that the ability of the government to meet the basic requirements of
persons with mental disabilities is pivotal. Does this mean that the buck rests with the government?
Health care is said be a human right and governments are enjoined to ensure that citizens have
affordable access to health care. Our study begs the question of how exactly affordable and
equitable health care may be achieved in Kenya, given that less than 1% of the health budget is
assigned to mental health [9].
Our findings may appear gloomy but not all pathways to change are rosy, and that indeed may be
the contribution of this reflection to the subject of employability for person with mental disabilities
in Kenya and other low-income settings. The important finding may be that it may not be possible
to achieve this lofty ideal by cutting corners and offering stop gaps as panacea to the problems. The
pathways to change must identify and solve perennial problems like poverty and stigma. Unlike
in most HICs, where welfare schemes such as supported employment have been successfully
implemented [10-12], self-employment schemes as an option to solving employment challenges in
low-income settings are not backed by evidence; and our study indicates that although the approach
has been embraced by many individuals, it has not solved their socio-economic challenges.
There are some silver linings and they indeed merit future exploration. On account of some of these
findings, and our feedback to Light for the World Netherlands, two specific actions resulted. First,
a training was organised for DPO coordinators in Kenya on psychosocial disability and the need
for inclusion of youths with psychosocial disabilities in its programme. Our study on challenges
associated with inclusion of youths with mental disabilities in TVET programmes in East Africa
underscored the importance of training people who work with DPOs on psychosocial disability [13].
Second, a group of about 15 youths were selected from around Kenya to participate in Light for the
World’s Mental Lab Challenge. The aim was to support the youths towards obtaining employment
by providing them with assistance in acquiring a disability certificate, health insurance, and training
in job skills, as well as linking them to employers.
The training conducted with and for DPO coordinators in Kenya in response to the observed
confusion regarding the difference between mental illness and intellectual disability is indeed
interesting and also interventional. This confusion not only resulted in the wrong information
being provided to frontline workers on disability inclusion, but ensured that persons with either
disabilities are wrongly categorised. The setting up of the Mental Health Lab followed this training
for DPOs. The experience of the youth beneficiaries provided a rich source of information on how
Stakeholder reflection on the results
221
11
factors such as disclosure to the employer, having health insurance, and possession of job skills may
influence employability. The information and findings may be scaled up in the country and in other
settings in which persons with mental disabilities have reduced access to employment.
11.4 Conclusion
This reflection may have raised more questions than answers, but it is also the essence of sharing
the study findings with stakeholders. The stakeholder meeting enabled us to better understand
some of the findings from the literature and initial empirical study. It highlighted the importance
of stakeholder involvement, rather than the ‘pipeline’ of evidence of implementation. Our study
sets the stage for the active participation of all stakeholders in communities that recognise the
importance of employment for persons with mental disabilities. The stakeholders’ recommendation
was to aim for clarity on the pathways to change through stakeholders’ affirmative action rather
than reliance on government policy statements.
CHAPTER 11
222
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of a mental health problem in the employment context: qualitative study of beliefs and
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A systematic review. PLoS One. 2017;12(12):e0189996.
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in Kenya. Kenya: 2018.
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Rehabilitation Journal. 2016;39(2).
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11
DISCUSSION AND CONCLUSION
C H A P T E R 1 2
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12. DISCUSSION AND CONCLUSIONIn this chapter, I discuss the highlights of the thesis by focusing on the main question:
What are the barriers to and facilitators of employability for persons with mental disability in
Kenya?
While the main question and sub-questions have been answered in previous chapters and articles,
this chapter discusses and summarises the main findings. It also describes the validity of the study,
the implications of the study findings for research and practice, as well as recommendations for
future research.
In order to answer the study questions, we adopted two different but interrelated methods. In the
first phase, we reviewed literature and policy documents while in the second we conducted a multi-
stakeholder mixed-methods study to identify the barriers to and facilitators of inclusion of persons
with mental disability in employment in Kenya. Seven studies (Chapters 4–10) addressed the study
questions. The factors were categorised as either barriers to or facilitators of employment for
persons with mental disabilities in line with the main research question.
12.1 Barriers to employment
Stigma and discrimination against persons with mental illness was a recurring barrier in the
literature reviewed. In the scoping review (Chapter 4), social stigma, discrimination, and negative
attitudes among employers were identified as major barriers to employment. Similarly, in the policy
review (Chapter 5), it was observed that although Kenya had ratified the CRPD – which prohibits
discrimination in any form and recommends that mental illness be regarded as a disability – the use
of derogatory language in national laws with regard to mental illness continued. This was identified
as a possible barrier to the employment of affected individuals [1]. In Chapter 5, social exclusion and
stigma against persons with mental illness was among the five clusters of barriers to employment.
Our findings in Chapter 6 indicated that 69.7% and 56.3% of persons with mental illness in Kenya
experienced discrimination in their workplace, or with retaining their job respectively. The findings
also showed that anticipated discrimination stopped 59.2% and 40.8% from looking for work or
studying [2]. Our findings on stigma as a barrier to employment for persons with mental illness are
supported by several studies [3-8] and aligned with a recent the report of the global summit on
disability that listed discrimination and stigma as among the major barriers to securing economic
empowerment for persons with a disability [9].
Among employers, we recorded negative perceptions of persons with mental illness, which was
accompanied by their unwillingness to employ them [2]. Negative perceptions included beliefs
that persons with mental disabilities were unproductive or likely to be violent in the workplace.
Negative employers’ beliefs about persons with mental illness have previously been documented
Discussion and conclusion
227
12
as a limitation to their employment [5, 10-12]. In Chapter 9, mental healthcare providers identified
stigma and social exclusion as limitations to the employment of persons with mental illness. The
negative attitude to mental illness was also related to ignorance about it, which was not only a
notable barrier, but also reinforced stigma and stereotyping. The lack of information about the
nature and reality of mental illness reinforces beliefs such as their inability to fit in the workplace.
This lack of information was noted in our studies with employers and DPO workers. Organisations
that ensure that policy and welfare frameworks are made available to those in need are pivotal to
the welfare of persons with disabilities. However, in Chapter 10, we observed that persons with
mental illness are left out or not recognised in most DPOs’ programmes [13]. This omission often
affects their inclusion in development programmes for persons with disabilities. Studies suggest
that the exclusion of persons with mental disabilities thrives on ignorance and misconceptions,
which further entrenches the myths about their inability to work [14-17].
Although the Kenya Disability Act made provisions for 25% tax rebates for those employing
persons with disabilities, the employers in our study (Chapter 8) were unaware of it and hence
none have ever applied for this scheme [2]. It was clear that some employers required help and
information on how to provide reasonable accommodation in the workplace, and the absence of
programmes for vocational rehabilitation or job coaching was suggested as being a likely barrier
to employment [2]. Only 15.2% of employers in our survey have ever employed person with
mental illness; most were unaware of the work ability of persons with mental illness This finding is
consistent with the literature and highlights the role of information to enhance inclusive practices
by employers in the workplace [14, 18].
Among DPO workers, mental illness used not to be considered as a disability and hence prevented
the inclusion of young adults with mental illness in vocational rehabilitation programmes that
lead on employment [13]. In the study on the lived experiences of persons with mental illness, we
also observed that such individuals faced challenges in obtaining disability certificates or proving
that their mental illness was ‘sufficiently’ disabling. This finding is supported by studies from both
low-middle and high-income countries (LICs and HICs) that consistently show the challenges that
persons with mental illness face in proving they have a disability [19-22].
Another significant barrier to employment common to all the studies is psychiatric illness and
its recurrence. In the scoping review (Chapter 4), we noted that the recurrent nature of mental
illness discouraged affected persons from seeking employment because they feared a relapse in
treatment. This was also reported in our study on the lived experiences of persons with mental
illness in Kenya as a barrier to seeking employment. Factors related to mental illness such as its
recurrence, and the side-effects of medication, were also reported in the studies. That stabilising
the illness was crucial to being able to work was recognised by both persons with mental disability
and mental healthcare providers (Chapters 6, 9 and 11). However, the likelihood of relapse was
expressed by persons with mental disability, mental healthcare providers and employers who felt
they needed reassurance that it would not happen (Chapters 6, 9 and 11). The ability of psychiatric
illness to limit a person’s participation in work and other activities of daily living have previously
been reported in the literature [16, 23]. Also related to the illness factor is the health system, the
CHAPTER 12
228
lack of access to which was a seen as a barrier in most of the studies. Mental healthcare providers
are responsible for attending to the health needs of persons with mental disabilities. They play
a very important role in ensuring their work ability through provision of optimal health care and
helping patients to maintain a balance between their health and work environment (Chapters
4, 6, 9 and 11). Mental healthcare providers suggested, however, that limited access to care
owing to a defective mental healthcare system, the lack of essential psychiatric medications, and
discriminatory insurance services directly and indirectly affect the workability of persons with
mental illness in Kenya (Chapter 9). The 2107 mental health Atlas highlights the defects in mental
health systems and especially in LMICs, where both financial and human resources for mental
health are scarce [24]. Sadly, according to the European Alliance for Mental Health – Employment
and Work (EUMH Alliance), there is no future of work unless a person enjoys good mental health
[25].
In addition to identifying the barriers to employment, our study also looked at facilitators of
employment for persons with mental disabilities. The factors that may promote employment for
persons with mental disabilities in Kenya follow closely from the observed barriers and although
most have been elaborated in the individual studies, a few are worth mentioning here.
12.2 Facilitators of employment
One common promoter of employment of persons with mental illness is stability of psychiatric
illness, as reported in our policy review (Chapter 4). This required the availability and affordability
of mental healthcare, and was reasserted in our studies with persons with mental illness who
bemoaned their challenges with mental healthcare and discussed how it would have made a
difference in their employment opportunities. This idea was also confirmed by mental healthcare
providers who regarded improved health care and government commitment to it as a relevant
pathway to improved employment for persons with mental disabilities (Chapter 9). Surprisingly,
employers also suggested that confirmation of the stability of someone with a mental illness would
boost their ability to employ persons with a mental disability. Moreover, employers in our study
insisted that disclosure of mental illness would promote the employment of persons with mental
illness because it would enable them make workplace accommodation for affected individuals [2].
This point is controversial because most of the persons with mental illness in the study identified
its disclosure as a barrier to employment. Studies from both the UK and USA recognise the
complexity of disclosing a mental illness to a prospective employer, and the dependence of the
reaction to disclosure to the work setting and location [26, 27]. For instance, a recent study in the
USA found that employees with mental illness who disclosed the fact to a prospective employer
in the setting of supported employment had positive more positive work outcomes than those
who did not disclose [26]. In low-income settings like Kenya, with a near absence of a supported-
employment model, there is no guarantee that disclosure would produce the same results.
A personal decision to work in spite of the challenges of illness was found to be useful to improving
employment opportunity. This was a key finding in the Chapters 4 and 6. In Chapter 4, we observed
that a personal decision to work despite the challenges associated with mental illness was integral
Discussion and conclusion
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to participation in work. Similarly, some study participants in Chapter 6 indicated that their personal
resolution to work was responsible for their engaging in employment despite their illness. This
finding from our study is supported by literature which suggests that personal factors such as self-
esteem and motivation are associated with work participation and productivity among persons
with disabilities [28, 29]. Self-effort and a personal decision to overcome the barriers of the illness
were regarded as pivotal to the uptake of care and decision to work. This notion also highlights the
role that personal factors may play in negatively or positively influencing an individual’s experience
of disability [30].
Another significant facilitator of employability for persons with mental disabilities is support at
the level of policy and legal regulations. Policy-makers play an important part in ensuring that
policy and legal recommendations guaranteeing reasonable accommodation in education, health,
and other spheres of life are available to persons with mental disabilities. However, our review of
policy documents in relation to the right to work revealed a gap between policy provisions and
practice in Kenya and other East African countries. Bridging this policy–practice gap would solve
over half of the challenges of employment faced by persons with mental disabilities. In the policy
review, we noted that making workplace accommodation was a useful facilitator of employment.
Accommodations such as flexible work schedules, reduced hours, supervision, modified job duties,
and job coaching for persons with mental illness are positively associated with employment [12,
23]. In addition, improved health care, addressing discriminatory laws and practice, and provision
of social welfare for persons with mental illness are possible facilitators of employment recorded
in most studies. These factors are directly or indirectly dependent on bridging the policy–practice
gap in Kenya and in many other low-income settings.
Although Kenya has ratified the CRPD, there is little or no evidence that its recommendations
have been adopted in practice. Yet, studies indicate that aligning national laws to the CPRD
is essential for the realisation of the right to employment for persons with disabilities [31, 32].
Our findings in Chapter 6 suggest that bridging the policy–practice gap in relation to persons
with disabilities in Kenya may promote their employment [1].
12.3 Stakeholders’ reflections on the results
In Chapter 11, we set out to obtain stakeholders’ responses to findings from the initial phases of
the study through a dissemination meeting and dialogue/reflection with them on the results of the
previous phases of the study. The dissemination meeting and dialogue session took place on the
same day. It entailed sharing of the researching findings with stakeholders, followed by a roundtable
discussion on identifying the pathways to employability for persons with mental disability in Kenya.
During the sessions, we explored four grey areas in order to arrive at a consensus on pathways to
improve employment for persons with mental disabilities in Kenya.
The grey areas relate to: 1) motivating employers/organisations to access the tax rebates available
for them under the Kenya Disability Act; 2) taking measures to ensure that government benefits
for persons with disabilities reach persons with mental disabilities; 3) enhancing job coaching or
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support for persons with mental disabilities in the workplace; and 4) improving access to health
care (e.g. through provision of essential and effective psychiatric medicines, non-discriminatory
insurance programmes) for persons with a mental disability.
In addition, we explored the experience of the stakeholders of an ongoing project by partners of
Light for the World Netherlands (LFTW) in Kenya. Following the initial findings from Phase 2 of
our study, LFTW evolved a programme (EmployAble 2) that incorporated a change in the youth
enrolment process in order to create more employment opportunities for those with psychosocial
disabilities. Moreover, in conjunction with LFTW, we developed a training programme for DPO
coordinators to facilitate understanding and inclusion of youths with mental disabilities in TVET
programmes. Furthermore, it gave rise to the redesigning and development of a second phase of
the LFTW employment programme, EmployAble 2, to enable youths with psychosocial disabilities
to be included in employment programmes. Hence, we also explored the practical and real-life
challenges (e.g. disclosure of mental illness to a prospective employer, access to health insurance)
observed in promoting employment opportunities for the youths with psychosocial disabilities in
the programme.
The stakeholders in the dissemination meeting noted a difference between the empirical findings
and the real-life experiences of persons with mental illness in the Kenyan context. Stakeholders
perceived that addressing the assumptions was difficult for a number of reasons. For instance,
although it is assumed that employers may be willing to employ persons with mental disabilities on
account of the tax rebates they stand to receive, the stakeholders pointed out that most employers
may be unwilling to share their business transactions with the national revenue authority. In
addition, the type of employers likely to employ persons with mental disabilities may be the very
ones who do not fulfil the eligibility criteria for obtaining tax rebates. Moreover, it was unclear how
to overcome structural limitations such as the bureaucracy and a protracted application process
to obtaining the disability certificate. Employers who decide to apply for the tax rebates would
need to show that their employees have a disability certificate, but even if they have one it does not
mean that the persons with mental disability would be willing to disclose this to their employer or
prospective employer.
Although disclosure was perceived as requirement for employment and obtaining reasonable
workplace accommodation, persons with mental disabilities and other stakeholders felt that it
would be a difficult personal decision, and assumed that it may not be easy to make it. Overall, it
was perceived that the pathway to improved employability for persons with mental disability is a
complex and multi-layered process that would work only if all the individual components were in
place.
On the assumption that available mental healthcare can ensure the stability of mental illness,
stakeholders pointed out that the experience of illness was different for different people and that it
requires that medication be readily available and free. However, it may be difficult to guarantee that
the government will honour its commitment to provide essential mental healthcare for persons
with mental illness. The stakeholders also pointed out that even if it were possible to achieve all
Discussion and conclusion
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12
these conditions, there was no guarantee that the Kenyan population would stop viewing persons
with mental illness as ‘mad’.
Having addressed the main research questions, we now address some main threads to employability
for persons with mental disabilities observed in our study.
12.4 Confronting the dearth of research and lack of political will in mental health
Study 1 (Chapter 4) revealed a dearth in research relating to the employment of persons with
mental disabilities in Africa. We initially set out to focus the review on East Africa, but the limited
number of identified studies compelled us to enlarge the scope to include the whole of Africa. Yet,
we identified only eight studies that fit the eligibility criteria of our study. Through these studies, we
identified five major clusters of barriers to employment, namely ill health, (anticipated) psychiatric
illness, social stigma and discrimination, negative attitudes among employers and the lack of social
support and government welfare. Moreover, based on the included studies, we identified five major
clusters of facilitators to employment, namely stability of mental illness, heightened self-esteem,
a personal decision to work despite stigma, competitive and supported employment, reduction in
social barriers/stigma, and workplace accommodation.
What is poignant about the findings of the study is the interrelatedness of the factors. Our use
of the biopsychosocial model enabled us to highlight the interplay of biological, psychological
and interpersonal factors, as well as how the contextual factors affect everything else including
employability (Chapter 4). While biological factors such as mental illness were a major limitation
to employment [33-36], they were closely related to and at times even exacerbated psychological
factors such as anticipation of the illness and loss of self-esteem. These effects further impaired
perceptions of the ability to work and retention of employment. As part of the psychological factors,
a personal decision to work featured as a significant barrier to and facilitator of employment. This
underscores the need to classify personal factors in the International Classification of Functioning,
Disability and Health (ICF) as both potential barriers to and facilitators of employment. It is,
however, important also to state that a personal decision to work may be contingent upon both
interpersonal (e.g. stigma, attitude in the work environment) and contextual (setting) factors that
are in operation around the individual with psychosocial disability.
In study 2 (Chapter 5), we explored the policy and legal provisions on reasonable accommodation
in the employment of persons with mental disability in 18 East African counties. We found that in
spite of the wide endorsement and ratification (83%) of the CRPD, there was a marked decline in the
real markers of compliance, such as the submission of a state report to the (44%) CRPD committee.
Only 11 of the 18 counties had an explicit definition of disability that includes mental illness. This is
unfortunate because the ratification of the CRPD implies acceptance of the intention to implement
its provisions. Article 1 of the CRPD clearly highlights the inclusion of mental illness as a disability,
but in most African counties – and Kenya in particular – persons with mental illness find it difficult
to prove they have a recognised disability. This finding represents a major policy drawback to the
employment of persons with mental disability. The provision of reasonable accommodation hinges
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on the acceptance of mental illness as a recognised disability. However, without policy recognition
or backing this would elude persons with disabilities. As a result, exercising the right to education
and health care, which are tied to the right to work and employment, would be impossible.
In our study (Chapters 5–10), we observed a common pattern in the use of derogatory terms in
reference to persons with mental disabilities. What is rather unsettling is that in Chapter 5, where we
reviewed legal and policy documents in relation to reasonable accommodation in employment, we
also observed the use of derogatory terms in reference to mental health as documented in the CRPD
committee report of the only four countries that have submitted a report [1]. This exemplifies a lack
of policy and legal framework to address the effect of institutionalised stigma and discrimination
on the employment needs of persons with mental disabilities in these settings. The ratification of
the CRPD does not translate to its implementation in the studied countries and the real markers
of compliance with the CRPD suggest that policies exist only on paper and not in practice. Thus,
our findings show that without research and political will, things will not change in mental health.
12.5 The outliers and resilience
In study 3 (Chapter 6) we reported on the lived experiences of persons with mental disabilities
and how they managed to secure employment or work in spite of their many challenges. In
this section, through the use of case studies, we highlighted the role of both the individual and
society in employment for persons with mental disabilities. Our results showed that despite the
complexity of the challenges faced by persons with mental disabilities, self-awareness of the illness
and a personal resolve to overcome the challenges are important for securing employment. This
observation was reported as instrumental to employment for persons with psychiatric disability
in South Africa [29, 37, 38]. Subjective as this may sound, it was depicted in the stories of our
study participants and anecdotal evidence from some who had siblings with mental illness with
rather negative life trajectories. According to some of the participants, their survival was owing
to their choice and acceptance of medication when their siblings had rejected them; their choice
to embrace education which offered them opportunities, while their siblings with a similar illness
chose to stay at home.
These stories may be outliers or evidence of resilience among those whose lived experiences have
led on to employment, notwithstanding the complexity of the challenges they faced. Individual
experiences in the social environment differ and coping mechanisms may also be related to
vulnerabilities that are not quantifiable. Matin et al. recommended a system of equitable resilience
that takes into consideration the contextual issues faced by individuals or groups in a socio-
ecological system [39]. This thesis highlights the difference in experience of employment for
persons in the same environment and facing similar vulnerabilities.
Therefore, while we draw lessons from the experiences of these individuals, it is important to
highlight that it may be different for others. It is pertinent once again to highlight the neglect by
the healthcare and social system which participants in our study suggest may be helpful to cushion
their experience of employment. Health care and inclusive social systems are inalienable rights
Discussion and conclusion
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12
that ought to be provided by governments as recommended in the CRPD [40]. Institutional and
system-level mechanisms are known to work to the benefit of person with mental disabilities [41,
42].
Our study also revealed a preference for self-employment by persons with mental disabilities.
According to the UK Department for International Development (DFID), self-employment and
informal work settings are preferred to formal employment by persons with disabilities [9]. While
we observed similar preferences in our study, self-employment may not be the best option for the
individuals in settings like Kenya without the social mechanisms of institutional support as seen
in HICs. In our study, reasons to opt for self-employment were on account of perceived stigma in
formal work settings and the inability to conform to their requirements and expectations.
12.6 The double stigma (mental illness and unemployment) pathway
Study 4 (Chapter 5) revealed the heightened rates of experienced and anticipated discrimination
against persons with mental disabilities in Kenya. Experienced discrimination stopped 69.7%
and 56.3% of the study population from finding or keeping a job respectively; while anticipated
discrimination stopped 59.2% from applying for jobs. This finding may be on account of two factors:
the prevalent cultural stereotypes against mental illness in Kenya, or the heightened awareness of
our study subjects, who were from ‘Users and Survivors of Psychiatry’, an organisation that doubles
both as a support and advocacy group for the rights of persons with psychosocial disabilities.
Furthermore, the overall gendered nature of experienced and anticipated discrimination was
observed, with women reporting more of it in their daily lives [43]. This observation has been
previously reported in different studies in India [44], UK [45] and USA [46]. We recorded a
significant association between impaired social functioning and unemployment, which mirrors the
observation of Tyrer et al. in their study of social functioning persons with psychiatric illness [47].
Our study reveals the overwhelming effect of stigma on account of mental illness. However, reported
stigma may also be owing to unemployment, or a combination of both factors. According to Staiger
et al., the twin challenges of unemployment and mental illness may lead to an experience of dual
stigma [3]. Hence, stigma from mental illness may lead to unemployment and unemployment may
lead to stigma which becomes a double tragedy for unemployed persons with mental illness.
12.7 A glimpse into employers’ expectations
In study 5 (Chapter 8), we documented the perspectives of employers in Kenya regarding the
employment of persons with mental disabilities. Our study revealed that only 15.4% of the
employers involved in the survey had ever employed persons with mental disabilities. This
dismal rate was found to be owing to the perception that persons with mental disabilities may
be unproductive or violent in the workplace. The attributions of unproductivity and violence to
persons with mental illness are two myths which studies suggest hamper employment for persons
with mental illness [2]. This perception was noted in the employers who participated in our study
in Kenya.
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Interestingly, we found that the possession of skills was the highest reported facilitator of
employment of persons with mental disabilities. This is very significant because it highlights that
the perception of unproductivity and violence are baseless and cannot be blindly applied to persons
with mental disabilities. The few employers who deviated from the negative norm helped us to
demonstrate that persons with mental disabilities are indeed able to work if given the opportunity.
Studies in both high- and low-income settings have shown that supported employment for persons
with mental illness is possible and very productive for both parties [41, 48-50].
We noted in this study that employers have expectations which influence the employment of persons
with mental disabilities. These expectations are not solely the traditional desire for profit but also the
need for disclosure and a genuine wish to understand how to provide reasonable accommodation
in the workplace [2]. In our study, some of the employers declared that in order to support persons
with mental disabilities, they require information and also disclosure in order to provide the right
form of support. However, disclosure of mental illness is a vexed issue because of the uncertainty
of an employer’s reaction [51, 52]. However, studies on inclusive employment also show that
reasonable accommodation cannot be made in an atmosphere of secrecy and ignorance [51, 52]. It
requires an exchange of information between employers and employees; perhaps, prior education
and information for employers to prepare them for the right attitude to handle disclosure.
12.8. Social- and health-system challenges limiting employment
Study 6 (Chapter 9) was undertaken to explore the perspectives of mental healthcare providers on
the factors that may improve employment for persons with mental disabilities. They suggested that
the interaction of socio-economic and health systems factors was responsible for the employment
challenges experienced by persons with mental disability.
Although the results were from two different countries (Kenya and Nigeria), we noted a similarity
in the perceived barriers to and facilitators of employment for persons with mental disabilities.
The effects of the socio-economic system within which the individual functions were considered
relevant for their experience of mental illness and related factors such as education, health care,
social network, and employment. It was instructive to note the declaration of one of the study
participants, a psychologist from Kenya, who observed that her clients, who were predominantly
of a higher socio-economic status and employed in big conglomerates, did not experience the
challenges of employment or access to health care that burdened the average Kenyan. The negative
impact of poverty on disability and mental illness in particular has been extensively documented
[53, 54]. Poverty experienced by persons with disabilities is regarded as a consequence of the
failure of a social system that excludes and disempowers the individual [53]. Furthermore, the
two-way relationship between poverty and mental illness has already been widely discussed [55].
Poverty increases the risk factors for mental illness while mental illness increases the likelihood of
poverty.
The effect of a defective health system was reported by healthcare providers from both Nigeria
and Kenya. It was considered responsible for the reduced access to mental health care, inpatient
Discussion and conclusion
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12
and outpatient mental health services, lack of health insurance and reduced access to affordable
medication. Our findings reinforce the need for universal health coverage and increased funding for
mental health [56]. An improved mental healthcare system would ensure that persons with mental
illness do not have to contend with the problems associated with untreated or poorly treated mental
illness. This would in turn ensure that they are fit to work and also enjoy other activities of daily life.
An effective healthcare system is pivotal to the employment of persons with mental disability.
12.9 Confusion as a barrier about what is mental disability
Study 7 (Chapter 10) used a formative research strategy to explore the perspectives of professional
in DPOs in four East African countries regarding the barriers and pathways to the inclusion of
persons with mental disabilities in TVET programmes.
We found that a complex interplay of factors affected inclusion of persons with mental disabilities
in TVET programmes. Using the ‘Structure, Culture and Practice model’, we found that interactions
between culture, structure, and practice presented either enablers or constraints to the inclusion
of persons with mental disabilities in those countries. For instance, the rigid TVET framework
operating in settings with heightened negative attitudes to mental illness led to the exclusion of
youths with mental illness in TVET programmes in East Africa. These factors affected all involved
actors as well as corresponding practices of inclusion.
We found that there was confusion in the definition and conceptualisation of mental illness. In
the interactions with NGO coordinators and managers of TVET, some of them perceived mental
illness as purely a medical ailment or impairment. It was therefore not regarded as a disability. Our
finding is similar to what has been documented in other settings across the world where persons
with mental disability were excluded from public programmes [20, 57]. This perception formed a
major structural barrier that affected the culture and practice of inclusion of persons with mental
disabilities in the TVET programmes. This unclear understanding of mental illness as a disability
enforced the stigma experienced by youths with mental illness and the attitude of both teachers
and TVET coordinators. We concluded that a clear understanding and definition of mental
disability was pivotal to overcoming the cultural, structural and attitudinal barriers to inclusion of
persons with mental disabilities in TVET programmes. This understanding also formed the basis of
an intervention training on mental disability for DPO and TVET coordinators in Kenya and Uganda
later in the study.
In the next section, we explore the study validity and the implications of the research.
Validity
Study-appropriate measures to ensure validity of methods and findings were adopted in all phases
of the research. Proactive measures were adopted to ensure internal and external validity.
Internal Validity
The internal validity of a study refers to the extent to which causal inferences may be made from
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a study; these are dependent on the researcher and research methods [58, 59]. The researcher
adopted measures in the study design to forestall errors of reactivity. In the various qualitative
methods used, such as interviews and focus group discussions (FGDs), open ended, and non-
leading questions were used. The research assistants were also trained in the process. Participant
selection for the qualitative study was purposive and was followed by a presentation of study
information. Consent was required before the interviews and FGDs. Interviews and FGDs were
conducted mainly in English; those conducted in Swahili were back translated. Data collection was
continued until saturation [60] was achieved in all phases of the research. The coding process for
the qualitative data was independently undertaken by two researchers, after which differences
were resolved in a joint meeting with the other researchers. The use of a mixed-methods study
design also provided an opportunity to perform researcher, data and methodological triangulation
and complementarity of results [58]. This ensured objectivity in the coding and interpretation of
the data. In order to limit the influence and agenda of the researcher, stakeholders were involved
in setting the research agenda; study participants were involved in the coding of part of the data,
and results of the analysis were shared with them during the manuscript preparations. Moreover,
during the study dissemination meeting further validation of results was undertaken by soliciting
the opinion of the stakeholders.
In the quantitative study, we used tools that were validated for the study setting via pretesting.
The Discrimination and Stigma Scale (DISC) has been previously used in a study in Kenya [61]
and is thus considered suitable for the context. This was also done for the researcher-designed
questionnaire; all the tools were translated into Swahili by native speakers who also back
translated it to ensure fidelity. We used random sampling in the quantitative studies to reduce
bias. The study instruments were self-administered, and assistance was also offered by the trained
research assistants for study participants who needed help. In the scoping and analytic review,
a data-extraction tool was designed by two researchers and all data extracted were reviewed
independently by two researchers, after which differences were resolved through discussions.
External Validity
External validity refers to the extent to which study findings may be generalised or applied
to different settings [58, 59]. At the inception of the study, we performed a scoping review to
understand available information on the study globally and in low-income settings. This enabled
us to reflect on our findings and how they relate to what is found elsewhere. The studies were
exploratory and drew attention to the need for further studies using longitudinal, transdisciplinary,
action-oriented and experimental designs.
The study with mental health care providers in Kenya and Nigeria, while not comparative,
nevertheless offers an opportunity to reflect on the similarities in perspectives and findings in the
two settings. The shared dearth of mental health research and services, and heightened stigma
faced by persons with mental illness, prepares researchers and policy-makers in similar settings for
the employment experiences for persons with mental disabilities, and the factors that may be useful
to improve practice. Although the selection of cases in the study on the lived experiences of persons
with mental disability was purposive, it highlighted the experiences of people in other settings who
Discussion and conclusion
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have managed against all odds to overcome systemic stigma and exclusion from participating in work.
Implications for research and practice
This section focuses on the implications of the result findings for research and practice.
Implications for research
Our findings point to a large research gap in employment for persons with mental disabilities
across Africa and in Kenya in particular. The sparse number of studies included in the scoping
review and their sub-optimal evidence level calls for more evidence-based research in this area.
There are hardly any intervention studies on employment models for persons with mental illness
in African countries. The importance of such studies cannot be overemphasised. The results from
studies on supported employment in HICs are helpful but context-specific studies in LICs and
MICs, with a dearth of social security benefits, are highly relevant. Using a cross-sectional study
design we explored the relationship between discrimination, social dysfunction, and employment;
but only longitudinal and intervention studies are likely to help tease out the relationship between
these variables. There may be need to explore the long-term effects of stigma and discrimination
on employment to test factors that may reduce their influence. Our study on the lived experiences
of persons with mental disability used case studies and qualitative interviews to derive answers
about barriers to and facilitators of employment for study participants. The strength of these
findings is limited by the study design; hence it would be beneficial for more robust studies to
identify the causal relationships between the identified factors. Future studies with larger sample
size and study participants from diverse groups and settings are also important.
Implications for practice
Our findings have many implications for practice, and these have been highlighted in the individual
studies. However, it is pertinent to discuss a few and make recommendations for practice. First,
it is evident that the acceptance of mental illness as a cause of disability is not recognised in
practice despite policy and legal backing. The rejection of mental illness as a source of disability
in TVET programmes needs urgent attention. It is obvious from the review of legal and policy
documents that there is gap between policy and practice in the recognition of mental illness as
a disability, as well as in perceptions about reasonable workplace accommodation. Obtaining a
disability certification for mental illness in Kenya is immensely difficult, and any changes to address
this bureaucratic bottleneck would improve the lives and work opportunities for persons with
mental disability in Kenya and also in other African countries. The propagation of stigma in legal
documents is also evident. Most of the countries that have ratified the CRPD still use derogatory
terms to refer to mental illness. It is no wonder, then, that individuals who work in DPOs, teachers
in TVET, employers, and indeed the whole society stigmatise persons with mental illness with
impunity, because it is endorsed in policy and legal documents. If the stigma associated with mental
illness is to be addressed then structural changes that underlie social attitudes and practices must
change; the complexity and interrelatedness of the factors that pose barriers to employment for
persons with mental disability must be recognised. In Kenya, these factors are rooted in systemic
and institutionalised discrimination, and determined efforts by policy-makers are essential to
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address them.
Recommendations
The pivotal role of improved mental health care is a recurring variable in all the studies. The WHO
Mental Health Gap Action Programme (mhGAP), and indeed various studies, point to the paucity of
mental health services in Africa [62, 63]. In Kenya, persons with mental illness face several barriers
to mental health care that have strong implications for their work ability. The unavailability of health
insurance for persons with mental illness and the unwillingness of insurance companies to cover
them is a matter of concern, and ought to be addressed by implementing the recommendations of
relevant laws. Devolution of health care may have several advantages in Kenya, but it has also left
the procurement of essential medicines in the hands of county governments that may be unaware
of the obligations of the national government as a signatory to international bodies like the CRPD.
Urgent action to address the problem associated with the affordability and availability of essential
psychiatric medication requires policy-level actions and implementation.
The findings of this thesis point overwhelmingly to the usefulness of family support and support
groups in coping with the problems of mental illness and employment. This is an important point of
reference for programmes that plan to address employment for persons with mental illness. Factors
and practices that engender support from families and support groups should be encouraged. The
uptake of health education and knowledge to reduce ignorance is another finding of the study that
is relevant for practice. Information aimed at important stakeholders, such as employers, would
improve attitudes and acceptance of persons with mental disabilities in employment. Ignorance
is rife and our study with employers showed a genuine thirst for information on how to provide
reasonable accommodation in the workplace. The role of disclosure in this must also be mentioned.
The dilemma of whether to disclose may always be with us, as in all matters for which there is
no perfect answer and for which we can never predict the response. However, mechanisms that
ensure that persons with mental disabilities seek and obtain redress when they are discriminated
against on account of their disability would increase and improve disclosure rates.
This study showed that self-employment is a genuine alternative to overcome employment
challenges. But it does not work for all [64] and would continue to be an add-on to government
input through social benefits. The role of the government as a duty-bearer cannot be
overemphasised and evidence from HICs shows that it works [41, 49, 50]. Supported-
employment schemes would not thrive without the support of government. The diversity of
human experience indicates that not all persons would graduate to competitive employment; for
those who are unable to, governments have a duty to ensure reasonable accommodation.
12.10 Conclusion
Employment for persons with mental disabilities is a human right and very relevant for socio-
economic independence and recovery. Self-reliance is an innate desire and few people desire a
life of dependence. The complexity of mental illness and unemployment is often taken for granted
but requires multi-level support to surmount. There are both overt and covert structural barriers
Discussion and conclusion
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that influence the inclusion of persons with mental illness because it is perceived as a socially
undesirable illness. Institutional mechanisms and implementation of legal recommendations
on reasonable accommodation in all spheres of life is relevant for the enjoyment of the right to
work by persons with mental disabilities. This thesis shows that multifaceted opportunities can be
explored to improve the individual’s experiences of employment and it shows that the expertise of
persons with mental disabilities, employers and other stakeholders, especially when shared, may
lead towards a more inclusive society.
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SUMMARY
Globally, mental illness is among the leading causes of disability, but the concept of mental illness
as a disability is often controversial and misunderstood. Persons with mental illness often suffer
in silence and the associated discrimination and social exclusion prevents them from obtaining
the assistance they deserve. Mental illness affects the poor and poverty worsens the outcome of
mental illness. The majority of persons with mental illness are unemployed, which often condemns
them to a life of poverty and dependency.
Inclusive employment is a human right and persons with mental disability have the right to
employment as enshrined in the United Nations Convention on the Rights of Persons with
Disabilities (UNCRPD). The principles of equity and social justice require governments and
employers to ensure equal employment opportunities for persons with mental disability, without
discrimination on the grounds of their illness. The aim of this study was to identify factors
influencing employability for persons with mental disability. In order to achieve this, we adopted
the research question:
What are the barriers to and facilitators of employability for persons with mental disability in
Kenya?
The study adopted a transdisciplinary approach informed by an understanding of the complexity of
mental illness and employment in the in low-income settings. Various study designs with multiple
stakeholders, including persons with mental disabilities, (potential) employers, mental health care
providers, mental health/disabled persons’ organisations (DPOs), family caregivers and policy-
makers. The study was conducted in three phases. The research question gave rise to three sub-
questions and seven study-specific questions which were answered in the first and second phase.
The third phase involved an attempt to evaluate the findings from first two research phases with
the stakeholders and identify pathways to change through reflection on the results.
Phase 1: Exploration
The first phase involved a systematic review of the literature and policy documents on employment
for persons with mental disability in East Africa. In the first study, we explored evidence in the
scientific literature regarding the barriers to and promoters of employment of persons with
psychiatric disability in Africa. We observed that social stigma, discrimination, and negative
attitudes among employers were identified as major barriers to employment for persons with
mental disabilities and that there was dearth of research on mental illness and employment. In
the second study we set out to determine the extent to which the UNCRPD recommendations
regarding reasonable accommodation for employment of persons with mental disabilities have
been translated into policy in East Africa. We found that although policies and legal frameworks
exist, there was little or no implementation of the recommendations that would ensure employment
for persons with mental disabilities in Kenya and other East African counties.
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Phase 2: Exploration by multiple stakeholders
The second phase involved a multiple stakeholder exploration of the study main question. We
explored perspectives on barriers to and promoters of inclusion of persons with mental disability in
employment in Kenya according to persons with mental disabilities, (potential) employers, mental
health care providers, and mental health/DPOs. First, we explored the experiences of persons with
mental disabilities in Kenya regarding employment through a mixed-method study. We uncovered a
complex interaction of factors such as the health system, stigma, discrimination and socioeconomic
status all influence the experience of mental illness and access to employment. Next, we used a
quantitative study to explore the extent to which experienced and anticipated discrimination and
social functioning affected the employment of persons with mental disabilities in Kenya. This study
revealed heightened levels of stigma and discrimination among person with mental illness, which
stopped many from seeking or remaining in work. Later, we sought to understand the perspectives
of employers regarding the employment of persons with mental disabilities in Kenya. Here, we
noted high degree of ignorance and misinformation regarding mental illness which were associated
with unwillingness to employ affected individuals. The possession of skills was the highest reported
promoter of employment for persons with mental disabilities. Generally, the employers considered
the disclosure of mental illness as crucial in order to make reasonable workplace accommodation.
As people with lived experience and employers alike emphasise the need for illness stability and
rehabilitation, mental health care providers may play an important role. We therefore used a
mixed-method study design to explore their perspectives on pathways to improved employment
for persons with mental disability in Kenya and Nigeria. The mental health care providers
identified a cluster of barriers to employment such as a defective health system, social stigma, low
socioeconomic status and lack of government commitment to social policies that could positively
affect the lives of person with mental disabilities. The identified pathways to improved employment
for persons with mental disabilities included improved information to reduce stigma, government
commitment to the health system and social welfare, and policy advocacy on employment. Finally,
as training and education are fundamental to employment, and people with a mental disability
may have missed out on educational opportunities on account of their illness, we investigated the
challenges of inclusion of persons with mental disabilities in TVET programmes in East Africa. We
observed that cultural (e.g. stigma) and structural (rigid curriculum) barriers in TVET programmes
impede the inclusion of persons with mental disabilities. The identified promoters of inclusion
include a flexible TVET curriculum, improved teacher training and inclusive attitudes towards
persons with mental illness.
Phase 3: Stakeholders’ reflection on the results
The third phase involved exploring potential pathways to improved employability of persons
with mental illness through reflection of the results from the previous phases with multiple
stakeholders. This phase was commenced but not completed. The part of the third phase presented
in this thesis involved a roundtable meeting where the findings of the first two phases were shared
and discussed with stakeholders, followed by a discussion on pathways to improved employability
for persons with mental disability in Kenya. The stakeholders acknowledged the complexity of the
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challenges and suggested that the involvement of all social stakeholders is relevant to establishing
the pathways to improved employment for persons with mental disabilities. In addition, they noted
the need for clarity on gradual approaches to change rather than relying on policy statements in
order to achieve a more inclusive society.
Conclusion
Employment for persons with mental disabilities is a human right and crucial to socioeconomic
independence and recovery. Self-reliance is an innate desire and few people wish to lead a life of
dependence. The complexity of mental illness and unemployment is often taken for granted but
requires multi-level support to surmount it. There are both overt and covert structural barriers
that influence the inclusion of persons with mental illness because it is perceived as a socially
undesirable illness. Institutional mechanisms and the implementation of legal recommendations
on reasonable accommodation in all spheres of life is relevant for the enjoyment of the right to
work by persons with mental disabilities. This thesis shows that multifaceted opportunities can be
explored to improve the individual’s experience of employment and that the expertise of persons
with mental disabilities employers and other stakeholders, especially when shared, may lead
towards a more inclusive society.
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ACKNOWLEDGEMENTS
This thesis is a product of the effort and support of several people and organisations. Even though
my heart is filled with gratitude; It may be impossible to recollect and acknowledge all whose effort
made this possible. For those I may have missed, I say thank you in advance.
I am grateful to the European Commission for the Erasmus Mundus Joint Doctorate (EMJD)
fellowship that enabled me to undertake the International Doctorate in Transdisciplinary Global
Health Solutions.
In a special way, I wish to thank my supervisors who made this journey possible.To prof. dr. Joske
Bunders-Aelen my promotor for all the great ideas; Dr. Barbara Regeer my co-promotor with
whom I labored in the last three years on the path to new knowledge and research; and to Dr
Mònica Guxens my second co promotor from Barcelona Institute of Global Health that was ever
ready to assist and guide me every minute of the day. I also appreciate Drs Elena Syurina, Dr Mitzi
Waltz, Dr Alida J. van der Ham, Mirriam Nthenge, Esther Rottenburg and Dr Renuka Nardodkar
who were my co-authors and contributed immensely to the content of this thesis.
I am grateful to Prof David Ndetei of African Mental Health Foundation (AMHF), Kenya that not
only hosted me in Kenya, but also supported me through my data collection in Kenya. Thank you
Dr. Christine Musyimi for the support on the ethical application process and indeed the whole
AMHF family. In a special way, I thank the friends who are like brothers that I met in AMHF-Albert
Tele and Isiah Gitonga for your support.
I thank the Users and survivors of Psychiatry Kenya especially Elizabeth Ombati and Michael
Njenga for linking me to their members and other study participants. I also acknowledge Vianca
Felix my intern who travelled to Kenya with me during the first field trip and assisted in the data
collection. I would seize this opportunity to again thank all my study participants and research
assistants in Kenya, East Africa and Nigeria. I thank Drs Chinyere Aguocha and Henry Chineke for
your support in initiating my study in Nigeria.
I am also grateful to Light for the World Netherlands for providing me the opportunity to work
with your partners in East Africa and evaluate your programs. The support of your organisations
provided me the opportunity to compare research evidence with real life situations; and for this
I am indebted to Matthijs Nederveen. Special thanks to Zina Olshanska, Judith Baart and Paul
Mbatia for your support through the process.
To the three persons whose teaching spurred my research interest: Profs. Peter Ikuabe, Dimie
Ogoina and Tubonye Harry, I thank you too. Meeting and learning from you enabled me to leave
the comfort zone of clinical practice to undertake this research journey. I cannot forget Dr Ifeoma
Onyeka the research mentor I have not met in person but who urged me on every step of the way
from the search for masters to doctorate scholarships. I am also grateful to Drs. Eunice Nwoke,
Chikezie Uzoechi, Rosie Mayston and David O’Flynn for all their support in this research journey.
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Acknowledgments
A
I thank Prof. Jude Egwurugwu, Dr Olakunle Oginni and Dr Bruno Chinko for being there for me to
think through my research ideas and Frankline Dike for all your help this last three years.
There are so many friends who made this journey possible. They are too many people; yet I wish to
thank the following who were fellow Erasmus Mundus Fellows -Dr Bain Luchuo, Vibian Angwenyi,
Dr Ona Ilozumba and Sarju Rai. I cannot count the number of times I made you solve my problems!
I am also grateful to the Athena family; especially Durwin Lynch, Astrid Kooijmans, and Floor Vogels
for patiently working on the thesis format. I also thank Dr Kenneth Anujuo for being my research
sounding board, I cannot forget Chima Nwakwuo for sending me the Erasmus mundus fellowship
application link and urging me to apply just a few days to the deadline .
Lastly I am grateful to my parents Theophilus Ebuenyi (who passed on few months ago) & Rose
Ebuenyi who sowed the seed of academics. My Brothers Chibuike and Chidi for reading my articles
and making contributions. I am grateful to my wife Chioma for enduring all the stress of the PhD
with me and my daughters Chizitere and Uchechi for sharing their father with this research.
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About the author
ABOUT THE AUTHOR
Ikenna Desmond Ebuenyi was born in Owerri, Nigeria. He graduated from Imo state University
Medical School, Owerri Nigeria in 2010. He worked as a resident doctor in the department of
Internal Medicine and Community Medicine at the Niger Delta University Teaching Hospital,
Yenagoa, Nigeria for about five years. He completed a Master of Public Health (MPH) at Federal
University of Technology, Owerri, Nigeria in 2015. In 2016, Ikenna completed a joint Masters
in Global Mental Health at King’s College London and London School of Hygiene and Tropical
Medicine having received the Chevening scholarship award.
Later in 2016, he received the Erasmus Mundus Joint Doctorate (EMJD) fellowship for an
International Doctorate in Transdisciplinary Global Health Solutions at Athena Institute, Vrije
Universiteit Amsterdam and Barcelona Institute of Global Health (ISGlobal), University for
Barcelona. His PhD research focused on inclusive employment for persons with mental disability
in East Africa. He has an innate interest in social and health disparities and his clinical and research
experience has revolved around mental health, HIV medicine, and disability inclusion. He is
presently a postdoctoral researcher at the Assisting Living and Learning (ALL) Institute, National
University of Ireland, Maynooth.
