Increasing employment opportunity for persons with spinal cord injury by digital working: an exampling case series from Thailand

Abstract

Introduction

Due to activity limitations and physical environmental barriers, low remunerative employment is a challenging issue for people with spinal cord injury (SCI) and relevant rehabilitation personnel. Since work opportunities in digital fields have continued to emerge, this study aims to report and discuss the possibility of using digital working as a strategy for increasing remunerative employment in people with SCI.

Case presentation

We report live experiences of four people with SCI in Thailand who have digital works with different types of jobs (image segmentation and identification for artificial intelligence development, online merchant, online streamer, cryptocurrency investor), different required digital skills (basic or intermediate digital skills), different employment statuses (employee or owner), and different incomes (from 50 to 200 USD/month). We also discuss advantages and potential risks of digital working for people with SCI and propose a model for care providers to facilitate safe digital work as a means of increasing remunerative opportunities for people with SCI.

Conclusion

There is increasing interest in becoming involved in various types of digital work among people with SCI. Digital working could overcome many of the physical barriers; however, it also potentially introduces some potential economic and health risks for people with SCI. To minimize those risks, healthcare providers of people with SCI should prepare to develop the appropriate knowledge and attitudes regarding digital working and to learn how to properly facilitate digital working to increase remunerative employment in people with SCI.

Introduction

Working situations of people with spinal cord injury

According to the International Classification of Functioning, Disability, and Health (ICF) framework, remunerative employment is one of the major life functions and is categorized into activities and participation [1]. Having opportunities for remunerative employment is one of the key goals for rehabilitating people with spinal cord injury (SCI) [2]. However, results of the International Spinal Cord Injury Community Survey (InSCI) found that the employment rate for people with SCI is still low, ranging from less than 20% in middle-income countries (e.g., Brazil, Greece, Morocco) to more than 50% in high-income countries (e.g., the USA, the Netherland, Switzerland) [2]. There are several factors responsible for the low employment rate in people with SCI, including lack of professional skills and low levels of formal education [3], environmental barriers including lack of accessibility, stigmas and discrimination associated with disabilities, as well as limited institutional and social support [4]. The low employment problem is a complicated and challenging issue both for people with SCI and for relevant rehabilitation personnel. Since some people with SCI have severe physical impairments, returning to work in pre-injury jobs could not be possible, especially for those with high physical demand jobs [5]. Appropriate vocational rehabilitation including job matching, a method to match between personal skills and preferences should be applied [6, 7] to identify a new job that might have an appropriate physical demand according to their impairments, such as a desk-type job [5].

The employment situation for people with SCI in Thailand

As a background, the following description of the employment situation for people with SCI in Thailand is provided. The estimated total number of people in Thailand with SCI is 64,000. Although there has been no validated data, this number has been calculated from the estimated incidence of SCI in the country, resulting in the incidence of 23 cases per 1,000,000 population per year [8]. The employment rate in the general population was 66.6% [9] but was only 39.5% among people with SCI [2]. The average salary is 14,620.5 baht or 465 USD per month. The current national minimum wage is 313–336 Thai baht, which is equivalent to 10–10.7 USD per day, but varies by province [10]. Presently, registered persons with disabilities (PWDs) in Thailand receive a monthly disability pension of 1000 baht (approximately 33 USD) if they are under 18 years old and 800 baht (approximately 25.7 USD) if they are 18 or over with an additional 200 baht (approximately 6.6 USD) if they are poor. Since the disability pension is very low, the earned income of persons with disability does not affect their eligibility to receive disability benefits [11].

The emergence of digital works and the possibility of using them to increase employment in people with SCI

One of the emerging desk-type jobs is digital work, which continues to expand concurrently with advancements in digital technologies. An individual can be engaged in digital work as an employee (full-time, part-time, or freelance), an owner (business owner, self-employed, or online investor), or both. Digital work can be classified as information and communication technology (ICT)-intensive jobs such as mobile application development or lesser intensive jobs such as artificial intelligence (AI) labeling or prompt creating for generative AI systems (e.g., ChatGPT), ICT-dependent jobs which could not be performed without digital technology such as online game streamers, and ICT-enhanced jobs which benefit from digital technologies but could be performed without ICT such as graphics designer [12]. Digital work requires various degrees of digital skills, including basic digital skills (performing web searches, sending emails), intermediate digital skills (digital graphic design, social media management, prompt creation for generative AI), and advanced digital skills (application development, network management, big data analysis) [12]. This study aims to report cases of people with SCI who were involved in digital working in Thailand and discuss the possibility of using digital working as a strategy for increasing remunerative employment in people with SCI.

Case presentation

Recently, the authors interviewed four people with SCI who were involved in digital work. After obtaining written informed consent, we interviewed each volunteer separately, both face-to-face and via telephone, using prespecified questions including type and duration of SCI, income, and perspectives regarding digital working.

The first case was a 32-year-old male with a bachelor’s degree who had been diagnosed with complete paraplegia T4 AIS A following an automobile accident 5 years previously. He was currently independent in all self-care activities, propelling himself in a manual wheelchair, and driving an adapted car. After being no longer able to work as an archery athlete, he decided to work with a digital company that provides AI labeling services. He heard news about this work from his friend who also lives with SCI. He had already had a computer notebook and a Wi-Fi internet system before being involved in this work. He spent average work hours of 8 h per week performing image segmentation and identification, i.e., to identify objects a customer needs in a picture and input the data (e.g., the name of the object) to create machine learning for AI via an online system. He had attended a half-day course with a qualifying examination before starting this job. for He declined to reveal his level of compensation, but from the company’s website, the cost of this work to the consumer was approximately 0.75 baht (0.022 USD) per picture or 50 USD per month. He said that this digital work, as well as producing little income, also made him not too much bored.

The second case was an 18-year-old 12th-grade graduate male who had been diagnosed with complete tetraplegia C8 AIS A after a car accident 1 year previously. He was independent in doing all self-care activities and controlling a motorized wheelchair but required minimal assistance in transferring to and from the chair. Before having SCI, he had worked as a waiter in an entertainment complex. He spent an average work hours of 20 h per week to work as an online merchant, trading items in an online game for real-life currency since he had sufficient time to play the game and was able to collect many items in the game. He heard news about this work from his able-bodied friend who was working in this job. He borrowed an old computer notebook from his friend and shared a Wi-Fi internet system at his friend’s home. He had no formal training for this work but informal training from video clip social platforms as well as asking/observing the work of other merchants in the game. He reported that he earned approximately 200 USD per month from this digital enterprise. He said he could earn some money from this digital work although he was not able to walk or to return to his previous job.

The third case was a 17-year-old male, an 8th-grade graduate who had been diagnosed with incomplete tetraplegia C5 AIS D after a car accident two years ago. He was independent in all self-care activities but required minimal assistance in transferring to and from the chair. Before having SCI, he worked as a dustman. At the time of the interview, he had spent average work hours of 28 h per week to work as an online streamer for three months. Each day he logs in to a streaming application and performs live broadcasts, greeting, talking to, and answering questions from the viewers. He got the idea of working as a streamer by himself after watching an able-bodied streamer channel. He used his smartphone for streaming and paid for a high-speed mobile internet system. He had no formal training for this work but informal training from video clip social platforms as well as asking/observing the work of other streamers. He reported that he earned from token gifts donated by program followers approximately 100 USD per month. He and his mother both reported that this work brought value back to their lives.

The fourth case was a 53-year-old male, a 10th-grade graduate, who was diagnosed with complete paraplegia T4 AIS A after a car accident 40 years ago. Two years ago, he was diagnosed with squamous cell carcinoma on the right buttock resulting from chronic pressure ulcer (Marjolin ulcer) post right sacrectomy. He was independent in doing all self-care activities and in propelling a manual wheelchair. In addition to his primary work as a lottery seller, he spent average work hours of 12 h per week studying and investing in cryptocurrencies, an online currency with highly dynamic price variability, using an online application. He got the idea for this work by himself after reading news about cryptocurrency booming. He used his smartphone for treading and paid for a high-speed mobile internet system. He had no formal training for this work but informal training from video clip social platforms and reading relevant weblogs and books. He traded cryptocurrency using short-term trading strategies and reported that he earned approximately 200 USD per month. All four of these people with SCI were satisfied with their digital work as it increased their income (although not to the level of their previous work), improved their confidence, and brought value back to their lives.

Discussion

Our cases demonstrate the live experiences of four people with SCI in Thailand who have digital works with different types of jobs (image segmentation and identification for artificial intelligence development, online merchant, online streamer, cryptocurrency investor). According to digital skills each job requires, image segmentation and identification for artificial intelligence development, online merchant, online streamer, and cryptocurrency investor require intermediate digital skills. However, digital knowledge and skills are obtainable since all individuals with SCI had not attended relevant formal education except a short education course for image segmentation and identification. Therefore, digital working may be possible for people with SCI who have no formal digital knowledge and skills but have an interest in digital working.

Advantages and potential risks of digital work for people with SCI

There are some advantages of remunerative digital working for people with SCI. First, this type of work could override the SCI-related impairment barriers from physical activity limitations [13], which are commonly faced by people with SCI as digital work can be adapted to specific disability conditions. People with paraplegia or low tetraplegia who can initiate extrinsic hand functions [14] as well as people with high tetraplegia who can use adaptive devices for touching the screen of a digital device can perform some types of digital work [15]. Digital working is also largely unhampered by workplace physical environmental barriers [13]. This independence is very important for people with SCI in low to middle-income countries who, in their daily lives, experience a higher incidence of environmental barriers, including public access and transportation over both short and long distances [16]. Although digital work involves digital products and technologies such as computers and internet networks, it has been reported that environmental factors related to digital communication devices are less problematic compared to other work situations [16]. Additionally, in Thailand, the internet is available to 77.8% of the general population [17] a mobile phone service is accessible to 97% of the general population, including both urban and rural areas [18]. Another advantage of digital working is that incomes from digital work are relatively high, especially among those who are digital business owners, compared with the Thai minimum wage of approximately 10 USD per day [11]. In addition, digital working has no country barriers. If people with SCI have access to digital devices and internet networks and can communicate in English, they can work for a US company while living with their family in Thailand. This advantage is, of course, potentially beneficial not only for people with SCI but also for the able-bodied population. After a new normal, post-pandemic of the Coronavirus Disease 2019 (COVID-19) era, which emphasizes physical distancing, some members of the able-bodied population might seek to shift from working in a specific physical location to long-distance working, increasing competition in the digital work labor market.

There are also some risks involved in digital work for people with SCI. First, spending most of the day on digital work might decrease real-life social activities and potentially result in psychiatric complications such as depression [12]. Second, some forms of digital work require specific skills which consume a lot of time for researching and planning. For example, a streamer needs time to create new content to keep followers from becoming bored, an online merchant needs time to obtain items that can be sold, an online investor needs time to research which type of stocks or cryptocurrency would be appropriate to buy or sell, as well as a programmer needs computational understanding and techniques. This increased workload might negatively impact on the time available for performing self-care activities and for looking after one’s health (biological time according to the conceptual framework of Dorricott [1985]) [19], potentially resulting in an increased risk of medical complications such as pressure ulcers, which people with SCI are at very high risk of developing [20]. This would increase a risk of injury-related secondary health conditions [13], which is also a barrier to sustainable employment in the future. Another risk is the questionable sustainability of some digital works. For example, streaming is trend-dependent and rumor-sensitive. Similarly, the values of some cryptocurrencies are extremely volatile and can change from a 200% decrease to a 200% increase in value in a single day, i.e., there is a high risk of loss [20]. To avoid such a loss, an investor needs to intensively research the market before deciding when and how much digital currency it is appropriate to buy or sell [21].

In our cohort, all individuals have the advantage of digital working by removing physical barriers. Image segmentation and identification for artificial intelligence development, online merchanting, online streaming, and cryptocurrency investing can be done at home. Regarding the advantage of relatively high incomes, the incomes of all types of works have no guaranteed salary and depend on the number of workpieces, such as the number of identified images, items sold, and life streams. Cryptocurrency investors also have a high risk of benefit, as well as loss. Therefore, the advantage of relatively high income as well as its sustainability needs to be further investigated. Regarding the specific risks of digital working, all individuals in our case series were involved in digital work as a part-time job, therefore, their work may not extremely disturb real-life social activities. According to the potential risks of complication from work-life imbalance, there was no evidence of increasing complication in our cohort, however, the fourth individual who was at risk of pressure injury from a history of grade 4 pressure injury should be closely monitored for pressure injuries since individuals with a previous history of pressure injury is a risk for developing a new one [22].

Roles of healthcare providers in facilitating digital workers with SCI

Although it is the right of people with SCI to choose what they consider to be the most appropriate work for them, it might be beneficial if healthcare providers, as part of providing environmentally supportive services [13], could advise people with SCI about how to begin digital working. Even if a health care provider is unfamiliar with digital work, they should respect the concept of people with SCI who want to work in digital fields and offer encouragement to individuals considering working in that area. Second, rehabilitation personnel who are responsible for delivering vocational rehabilitation, e.g., occupation therapists, vocational therapists, assistive technologists, and social workers, should try to learn something about digital work. Third, healthcare providers should be alerted to monitor for potential complications related to prolonged sedentary behaviors, e.g., pressure injuries, in people with SCI, especially individuals who are beginning digital working for the first time.

Another supportive role of health care providers is to evaluate whether individuals with SCI need help in facilitating beneficial environmental factors, including gaining access to digital devices and communication services such as computers, mobile phones, and internet networks, as well as to assist in extending its possibility according to the political regulations of each country. Healthcare providers of people with SCI can also try to understand the point of view of employers and their workforce systems in areas such as work ethics related to health conditions and supportive tax and employment policies and laws. Shortly, a specialized vocational rehabilitation (or habilitation) services program for digital works should be developed to maximize the benefits and minimize the risks for digital workers, including helping individuals with SCI to develop an economic plan as an environmental facilitating factor. Such a program might also include physical and occupational therapy, as well as assistive technology services for enhancing the capacity of people with SCI to perform digital work. Also, a custom-made vocational job matching [6, 7] and follow-up program [23] should be provided to ensure that people with SCI achieve an individualized, patient-centered, sustainable employment situation. A professional society, e.g., a committee or subcommittee of the International Spinal Cord Society (ISCoS) or the American Spinal Injury Society (ASIA), should be involved in developing this service and helping developing important instructional materials and guidelines. Unfortunately, although the four people with SCI in this study who were involved in digital work are from Thailand; however, to date, there is no specific strategy for enhancing digital work opportunities for people with SCI in that country. The benefits and potential risks of digital work, as well as the roles of healthcare providers in taking care of people with SCI who are performing digital work, are summarized in Fig. 1.

Fig. 1. Advantages and potential risks of digital working in people with spinal cord injury and roles of health care providers.

SCI spinal cord injury.

Conclusion

There is increasing interest in becoming involved in various types of digital work among people with SCI. Digital working helps these people who are seeking to become involved in meaningful, remunerative working to overcome many of the barriers related to SCI. Digital working does, however, introduce some potential economic and health risks for people with SCI. To minimize those risks, healthcare providers and those who care for people with SCI should be encouraged to develop the appropriate knowledge and attitudes regarding digital working in people with SCI and to learn how best to prepare those people to seek remunerative work commensurate with their abilities in this digital age.

Author contributions

SP was responsible for designing the research questions, interviewing the patients, drafting the manuscript, and writing the final version of the manuscript. PP was responsible for designing the research questions, interviewing the patients, and commenting on the final version of the manuscript. US, TH, SaP, and NS were responsible for designing the research questions and commenting on the final version of the manuscript.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Competing interests

The authors declare no competing interests.

Statement of ethics

The authors certify that in our institute, deidentified case series are waived from ethical approval. Written informed consent was obtained from each participant under national regulations.