Facilitators and barriers to employment for persons with chronic spinal cord injury or disorder: A qualitative study framed by the person-environment-occupation model

Abstract

Context/Objective:

Prolonged unemployment is common for people living with a spinal cord injury or disorder (SCI/D) and can impact negatively on quality of life. The present study examines stakeholder perspectives and experiences with the job search process in order to identify service gaps and return-to-work solutions.

Design:

In-depth semi-structured interviews were thematically analysed, with questions focused on factors that can help or hinder efforts to gain employment. Generated themes were then applied to the Person-Environment-Occupation (PEO) systems model of participation.

Setting:

Community-based disability service provider in South Australia.

Participants:

Purposive sample of persons with SCI/D (n = 8) and rehabilitation professionals (n = 4).

Results:

Person-centred themes were strongly endorsed by both groups and focused on incentives of, and motivation for, employment. Equally important to the job search process were individual expectations and attitudes, particularly job readiness. Environmental facilitators included employers’ positive attitude, although workplace discrimination remained a concern. Occupation-based barriers, rather than opportunities, were identified – namely, difficulties in SCI/D self-management, the need for timely functional assessments, and more opportunities for education, upskilling and retraining.

Conclusions:

The PEO model provides a broad framework to better understand the complex return-to-work process for people with a SCI/D and, potentially, uncover tangible solutions. The suggestion is that vocational rehabilitation should go beyond skills training and include motivational support to enhance job readiness. This must be done on a case-by-case basis. There is also a need for active and covert discrimination to be addressed through employment policies. The findings will be used to develop intervention targets for a newly established vocational rehabilitation service.

Introduction

A critical aspect of independent living for those with a spinal cord injury or disorder (SCI/D) is successful return-to-work. The benefits of competitive employment extend beyond economic self-sufficiency. Work fosters a sense of identity and has been linked to longevity.^1–3 However, employment rates of persons with SCI remain well below those of the general population – even in high income countries.^4–6 Furthermore, there is considerable variation in the vocational rehabilitation approaches currently used for persons with a disability. This is especially the case in Australia, with over 200 private and taxpayer-funded corporations providing employment support services – with varying success rates.^7,8 The wide variability in service provision and quality makes it difficult to delineate the key features of effective return-to-work interventions.⁹

Notably, much of the vocational rehabilitation research with SCI/D is quantitative and overly focused on point-in-time outcomes (e.g. employment status at two years post-injury). As a result, there is a relative neglect about pathways to successful post-injury employment in the competitive job market (see Bloom et al.,¹⁰ for a recent review). The few qualitative studies that have explored stakeholder perspectives of successful return-to-work highlight the importance of effectively engaging with consumers about their employment options, wishes, experiences and identified needs.^11–13 Equally important are the perspectives of health professionals and disability service providers, who can help to elucidate the challenges of providing person-centred return-to-work interventions.^14,15

When combined with theory and context, stakeholder perspectives provide a strong basis for intervention. One such framework is the Person-Environment-Occupation (PEO) model –^16,17 which has been successfully used for assessment and intervention planning in acute care.^18,19 Based on theories of help-seeking, environment-behavior, and occupation, the PEO model acknowledges the reciprocal relationships between: (1) a person’s identity, interests and experiences; (2) their broader social, physical, economic and cultural environment; and (3) the tasks, roles or occupations that they perform within this context. Congruence between each domain is critical not only to occupational performance but, in the context of return-to-work, job satisfaction. It follows that successful return to work for the job-seeker with a SCI/D requires the individual to have knowledge, skills and interests consistent with the position in addition to necessary supports and training – whilst the job itself needs to be sensitive to SCI/D issues. Conversely, a mismatch between domains can exacerbate disability – as when job demands or processes exceed one’s physical, cognitive or emotional abilities.^16–19 Despite its promise, little is known about the application of the PEO model in vocational rehabilitation.

Current study

In sum, there is still much to learn about the employment experience for persons with SCI/D, including facilitators or barriers faced when entering or re-entering the job market. We address this aim in the present study by exploring key stakeholders’ experiences of seeking and gaining employment following SCI/D, using the PEO model to guide our research conceptualization.

Methods

Design

In-depth, semi-structured interviews were used to examine return-to-work experiences and perspectives of adults living with chronic SCI/D. Interviews with rehabilitation professionals (2 vocational consultants, 2 managers) provided opportunity to triangulate the findings with another group and identify additional facilitators and barriers to the job search process.

Sample characteristics

Eight participants (6 male, 2 female) with an average age of 45 years (range 37–58 years), were interviewed. Most had sustained traumatic paraplegia (n = 5; T3–L2; 14–30 years post-injury). Congenital causes included spina bifida and RASopathy. Participants had varied work histories: four were employed on a contractual or part-time basis and four had been unemployed since their injury although wanted to return to work. The four rehabilitation professionals interviewed had over 60 years (range 15–40 years) of combined experience in neurological rehabilitation, with postgraduate qualifications in occupational therapy, social work, nursing and management.

Setting

The study was conducted in a not-for profit organization in South Australia that provides multidisciplinary services (i.e. nursing, occupational therapy, peer counseling, social work, vocational counseling) and advocacy for persons living with a SCI/D, and their families, across the continuum of care.

Eligibility and recruitment

Ethics approval was sought from the University of Adelaide Human Research Ethics Committee (approval number HREC 2019_050). Eligibility criteria included persons of working age (16-65 years) with an acquired SCI or neurological disorder of the spine. Purposive sampling was used whereby members of the participating organization, regardless of employment status, were emailed the study details inviting them to reflect on their own experiences of job searching. In addition, all rehabilitation professionals involved in the organization’s vocational counseling service were contacted and consented to be interviewed.

Data collection

Interviews were conducted from June to September 2020 by two researchers (A.CH, E.M). Video (Zoom) conferencing was the preferred method of interview (n = 10), with one participant requesting a telephone interview, and another receiving the prompt questions and returning written responses via email. Regardless of interview method, all participants were asked the same questions, focusing on their backgrounds and experiences of employment and employment support services in addition to their recommendations for improved supports (see Tables A1 and A2 in Appendix for interview schedule). The semi-structured prompts allowed scope for participants to move outside of the prompts and give voice to their experiences and thoughts. Both visual (Zoom) and audio (phone) interviews, which ranged from 23 to 59 mins in duration, were recorded and transcribed verbatim by a third researcher (E.P), with de-identified transcripts labeled with the participant type (person with SCI/D, rehabilitation professional). Consistent with member-checking protocol,²⁰ all participants were offered the opportunity to edit their transcripts. Both interviewers, who also conducted the data analyses, have a background in psychology and qualitative research: A.CH is an experienced health psychologist, E.M is a trainee psychologist. The transcriber (E.P.) is a qualified occupational therapist.

Data analysis

The thematic analysis was conducted according to the framework outlined by Braun and Clarke.^21,22 To ensure consistency and trustworthiness, each interviewer/analyst cross-checked the generated codes and themes and agreed on salience. Rigor, transparency and self-reflexivity were demonstrated by having each interviewer maintain an audit trail, documenting notes on the methodology and reflections on interviews.²³ As two different people conducted the interviews, the interview data corpus was read in entirety by both interviewers, along with the audit trails. The preliminary themes developed by the first interviewer (E.M.) were then examined by the second (A.CH), and vice versa, and discussed. The final themes were drafted by E.M. and then checked by A.CH back to the raw data and the audit trails. The first author (D.D.) then arranged each theme according to the relevant PEO domain. The themes, per se, did not change in this process. The final themes were considered by all authors – adding further to trustworthiness and rigor. Analyses were performed sequentially, with no new information appearing during the final interview – indicating that saturation had been met.²¹ Saturation was decided through a process of constant comparison, which commenced from the first interview onwards – that is, we made the decision to cease data collection at the final (12th) interview, based on the preceding eleven interviews.

Results

Both groups identified various factors, perceived to be facilitators and barriers to the job search process for persons with SCI/D. Practical suggestions for return-to-work service provision were additionally provided. Key themes with illustrative quotes are described below and organized by PEO domain, with a detailed list of codes provided in Tables 1 and 2.

Table 1.

Key themes and associated codes for each PEO domain.

PERSON
Facilitators	Financial incentive (5 SCI/D)	Motivation – Social (7 SCI/D, 2 RP)	Motivation – Identity (7 SCI/D, 3 RP)
	Financial gain Need to save for retirement Financial freedom-travel /spending money	Social interaction Make friends Point of discussion (What do you do?) Want to help others	Identity revolves around vocation Sense of pride Young people tend to be more motivated “That’s just what people do”
	Motivation – Quality of Life (8 SCI/D, 4 RP)	Individual (7 SCI/D, 2 RP)
	Sense of normalcy Self-worth Purpose Reason to get up in the morning Boredom/spare time Avenue to pursue interests Helps manage emotional distress	Positive attitude Attitude to disability How you present yourself Independent Intelligent Having transferrable skills Having a job prior to accident
Barriers	Finance as a disincentive (5 SCI/D, 2 RP)	Individual (8 SCI/D, 4 RP)
	Salary has to be greater than pension Some return-to-work service cost: can’t afford	Being older in age Not interested in early intervention Not motivated to take up opportunities Personality type Lack of confidence Not wanting to go out Own expectations about abilities Own perceptions about work and identity Perception that it’s too hard to find a job
ENVIRONMENT
Facilitators	Employer attitude (8 SCI/D, 4 RP)
	Flexible with work arrangements Open to discussion Modified work hours/arrangements Accessible workplace Job-person fit (i.e. work aligns with passions, interests)
Barriers	Discrimination (5 SCI/D, 2 RP)		Social support (4 SCI/D, 1 RP)
	Employers can’t be bothered Employers scared Assumptions about ability – ableism Dismissed after supplementary wage assistance finished Interviews not offered when resume mentions disability Fear of retribution if injury is a workplace accident Difficult to return to work if employer doesn’t like client prior to accident Covert discrimination “You just don’t meet the requirements” Used as “cash cow” in wage subsidy scenarios Congenital injury discriminated against more than accidental injury		Generational unemployment Busy at home with family
OCCUPATION
Barriers	SCI self-management (8 SCI/D, 4 RP)	Job-person-organization fit (4 SCI/D, 3 RP)	Education and skills training (6 SCI/D, 3 RP)
	Busy managing health Busy with rehab taking up most time Depending on injury, might need high levels of care Care products are expensive Medication and their side effects Comorbidities – chronic pain, bowel/urinary complications, mental health (anxiety, depression, substance misuse) Dealing with grief and loss	Placed in unsuitable job Physical tests to prove people aren’t worth the award rate Health and safety concerns at work Wages cut because “not working at full capacity” Agencies under pressure to meet KPIs – interested in signing people up, not the outcome Generalist support services don’t meet individualized SCI/D needs Other agencies slow moving Working cross-purpose with various agencies	Internet access (for study options) Very hard to study in-person Not knowing who to contact Haven’t had opportunity to find out what they’re good at Lack of experience in chair Don’t know what they really want to do Fear of navigating personal interactions and environment

Table 2.

Generated codes focusing on improvements to return-to-work services, organized by PEO domain.

P: Person-centred approach	E: Build and enhance available resources	O: Occupational assessment, training, education
Ask people why they want a job, not just “what job” Treat people as individuals Find a good fit for a person’s lifestyle and goals Build rapport Make it personal	Make vocational rehabilitation a priority Assistance to deal with discrimination Presence of vocational rehabilitation staff on ward Educate inpatient staff that vocational rehabilitation is an important part of discharge planning Integrate vocational with medical rehabilitation Have a cohesive team to share resources	Clients want to know their functional capacity before looking at jobs. Provide education about study pathways Compile resource lists (e.g. how to write a CV, who to contact for certain things etc.) Help with CV Education on navigating the job-seeking process with a disability (e.g. interviews, disclosures on CVs) Advocacy and help explaining SCI/D needs to employers Bulletin board with employment and training opportunities Expand network of potential employers, not just jobs in the disability sector Build strong relationships with potential employers

Personal domain

Incentive and motivation

Both consumers with SCI/D and rehabilitation professionals identified intrinsic motivators for returning to work. These included opportunities for social interaction, its positive influence on quality of life (i.e. improving mental health through a sense of normalcy, self-worth, self-esteem), and the belief that work can provide a sense of purpose and personal identity (work is part of who you are). In particular, individuals needed to feel that work, and their work role, was meaningful – encapsulated as the “why” of work:

It comes down to your reason why … the reason that I want a job, is because I want to, I like the feeling of contributing. [P3, person with SCI/D]

Persons with SCI/D additionally emphasized the financial benefits of a steady income to “have a really good life.” [P1, person with SCI/D]. Conversely, rehabilitation professionals were concerned about the incentive to find a job for those already in receipt of an income support payment from a personal injury insurance or government assistance scheme (e.g. Disability Support Pension requires recipients to work for less than 30 h per week). Dependent on the level of support payments received, employment for some with SCI/D was seen as a disincentive:

… often they don’t want to work because they get, um, you know, income support anyway … . [P9, rehabilitation professional]

Individual expectations and attitude

The degree to which a person with SCI/D actively participated and committed to the job search process stemmed from their own expectations and attitude towards their disability. All participants identified individual attitudes as a major facilitator to finding work but also a barrier that needed to be challenged:

Some people don’t want to return to work. They’ve had their injury now and this is how it is, and they have trouble, you know, accepting that. So, they’re not even open to discussion about work and things like that. But certainly the ones that are interested in engaging, they’re open to all sorts of ideas and suggestions. [P5, person with SCI/D]

A key factor in determining how motivated an individual was in finding work was their job readiness, or their ability to engage and persist in the job hunt despite experiencing failure and rejection. Readiness was identified as a factor driven largely by the individual:

For me, my first years after my injury, was, I was just focused on recovery. I didn’t want to go back to full-time work. [P7, person with SCI/D]

A tailored approach to employment support that requires “tapping into” an individual’s motivations for finding a job – was therefore deemed important by all. Rehabilitation professionals, in particular, were focused on the longer-term goal of helping people choose a vocation that aligned with that person’s goals and interests and could “engage” them. [P10, rehabilitation professional].

Environment domain

Employer attitude

Whilst both groups highlighted the value of extrinsic factors influencing successful job search behavior, including a good wage and workplace conditions, equally important was an employer’s attitude to disability. Specifically, employers needed to be flexible and open to discussion about appropriate workplace modifications. Concern was expressed about employers overestimating the costs of hiring someone with a SCI/D and having stereotypical assumptions – including the assumption that disabled workers will not have the right social “fit” or will take a lot of time to manage:

… and then it is the attitudes of some people because they have automatic assumptions about what we’re capable of, how much management we’ll need, how much sick time we’ll have off. [P1, person with SCI/D]

Discrimination

Both active and subtle forms of workplace discrimination were identified by those with SCI/D. Disclosing disability was a contentious issue – whilst many acknowledged that disclosure as early as possible (e.g. in a job application) was important in order to help employers respond effectively to hiring a person with a disability, concerns were expressed about the negative consequences of this:

I think the biggest thing for me was getting my foot in the door, and for an interview. I tried to be honest in my cover letter, you know, saying I’m a wheelchair user, but still able to do most things. And just got totally ignored, to the point where I wasn’t sure, you know, do I not be 100% honest and just apply for the position and then roll up in a wheelchair and then shock them. [P7, person with SCI/D]

Additionally, government-funded wage-subsidy schemes which should, in theory, provide an incentive to employers to hire people with a disability – typically only provided short-term financial support. Consequently, those with ongoing, specific support requirements might not be considered for a permanent position:

… the employer is supposed to keep you on and give you wages, give you a job basically. Um, the theory is a little different from the reality, in a lot of cases. [P1, person with SCI/D]

Social support

Individuals with SCI/D recognized the value of pre-existing social networks – whether through family or previous employers – as a crucial element in identifying and gaining potential jobs. Conversely, generational attitudes to work – where the family has a history of unemployment – was discussed as hampering engagement with, or re-entry to, the workforce:

If you’ve got a motivated family, you’ve got people around you that are doing stuff, are motivated, are there, you’ve got an employer that wants to get you back into the system, then you’re half way there already. [P6, person with SCI/D]

Rehabilitation professionals, in contrast, focused on the need to enhance and build on existing professional supports. There were, however, mixed views within this group on the appropriate time to begin return to work discussions and what that discussion might look like. For some, the presence of a vocational counsellor in the hospital setting was considered particularly important for discharge planning, helping to reinforce the importance of vocational and career education soon after SCI:

I do think that that acute sort of presence of a vocational counselor within the acute rehab setting is vital, because that’s where the seed, really, is planted, that returning back to work is a possibility, and it’s something that can be achieved. [P9, rehabilitation professional]

Others expressed concerns about patients’ competing time commitments and information overload during inpatient rehabilitation – particularly for those still recovering, physically and emotionally:

Because when they’re in rehab, they’re bloody busy … most of their day is in and out of treatment times. So, fitting in an amount of work plus rest time, which is really, really important, is not necessarily appropriate for that client. [P6, rehabilitation professional]

Occupation domain

SCI/D self-management

Participants with SCI/D discussed anxieties around living with their disability and how this might hamper their ability to be in the workforce. Concerns were raised about how they might manage secondary medical conditions or complications such as depression, neuropathic pain, and bladder and bowel continence:

If you wake up and you’ve had a terrible, terrible day, and you’ve had a massive bowel accident, and someone’s going to come and talk to me about a possible job this afternoon, I’m going to be thinking “There is no way I can go out and get a job if I’m going to crap myself like this.” [P6, person with SCI/D]

The likelihood of optimal employment outcomes was increased when individuals were empowered to take responsibility for their physical self-care. Rehabilitation professionals highlighted a need to address individuals’ concerns about living with a disability and working, through continual information sharing as “information is powerful” [P13, rehabilitation professional]

Job-person-organization fit

Both groups highlighted the need to ensure good person-job fit. Functional capacity assessments were considered a necessary first step so that individuals with SCI/D could better understand and manage their job skills, abilities and expectations. Equally important was a need for work roles and responsibilities to be analysed and modified in a graduated way to suit an individual’s requirements, particularly for those with medical comorbidities:

I think what stops people are things like pain, people’s physical capacity to be able to sit for periods of time, to be able to concentrate for periods of time, you know, those kinds of things. [P12, rehabilitation professional]

However, persons with SCI/D also flagged concerns about employment support services being less focused on the individual’s needs and wishes, and more on getting the person into the open job market – regardless of whether the job is suited to them, oftentimes to serve an agency’s purpose:

… they’re under a lot of pressure from the government. They’ve got KPIs [Key Performance Indicators]. So they’re not always necessarily trying to find you a job that suits you. I know we can’t always pick and choose, but I know some people who have been put into jobs. [P3, person with SCI/D]

Education and skills training

Further education, upskilling and retraining – depending on whether the goal was to teach new skills or reinforce existing skills – were seen as important in order for an individual to remain competitive in the open job market. This included study options through adult and community education providers (e.g. Technical and Further Education; TAFE). Education was, however, seen to be difficult when online study options were not available:

As part of my spinal injury I have incontinence. If I’m having a really bad day, I can’t leave the house. [P1, person with SCI/D]

Both groups suggested a range of educational and support strategies to promote employability skills. This included information regarding study pathways and training scholarships; support navigating the job-search process with a disability (e.g. what to disclose in applications for interviews); and advocacy to explain SCI/D needs to potential and current employers. Specific actions that return-to-work services could implement included: circulation of bulletins or e-newsletters with employment and training opportunities specific to persons with a disability; links to online resources (including contacts, assistance with curriculum vitae writing, dissemination of research findings); and opportunities to engage with prospective employers (e.g. job expos).

Discussion

Consumers and rehabilitation professionals identified multiple factors that interact to help or hinder the job search process – themes that aligned well with the PEO model (see Fig. 1). Use of the PEO model in this study also uncovered tangible solutions that can help persons with SCI/D succeed in securing work.

Figure 1.

PEO model of return to work following SCI/D.

The emphasis on personal factors highlights the importance of exploiting facilitators to employment – particularly intrinsic and extrinsic job incentives. Consistent with theories of motivation, individuals will pursue a job if work is considered meaningful and valuable to them, but also because of the immediate rewards – for this sample, the financial and psychosocial benefits of employment.^9,24 In order to persist in the job search process, however, job-seekers need to have a reasonable chance at securing competitive work. It is therefore critical to manage some of the key barriers to job-seeking. Medical complications of SCI/D, a primary concern for the consumers we surveyed, can be addressed through lifestyle advice, skills training and support to promote health behaviors.²⁵ Such intervention needs to be done on a case-by-case basis, with consideration given to the individual value placed on work. For this reason, job search motivation and job readiness should be routinely assessed during vocational rehabilitation^26,27 – particularly given that that each PEO component is dynamic and changeable across the lifespan.¹⁸

Our sample also identified a need for employment support and advice to be made available throughout the continuum of SCI/D care to help individuals prepare for, and gradually engage in work.^28,29 However, whilst the importance of close, personal contacts was recognized, the strong contribution of distant acquaintances (i.e. ‘friends of friends’) in contemporary job searching was not. There is substantial theory and data to suggest that social contacts and networks are an influencing factor in successful job-seeking.^30–32 Social networking strategies (e.g. LinkedIn) are particularly important in order to make novel connections within an industry.

Notably, occupational barriers were readily identified – but not facilitators. Competitive jobs were considered to be inaccessible, with concerns expressed about workplace inclusion for persons with a physical disability. Social cognitive theory highlights the importance of promoting self-efficacy and outcome expectations to help individuals’ beliefs about coping with such barriers.³³ In this context, workplace assessments using job matching tools specific to SCI-needs are critical to ensure both job-person and organization-person fit.^34,35 Vocational counseling alongside on-the-job support can also help to prepare persons with SCI/D when entering the labor market.³⁶ Similarly, employers would benefit from education about how to maximize work engagement and productivity for people with disabilities.

In sum, the PEO model offers a framework to conceptualize vocational rehabilitation interventions for those with chronic SCI/D. Future research with a heterogeneous sample, including individuals with more recently acquired injury (i.e. <5 years post-SCI), will help to determine whether the model is appropriate to apply across the continuum of care. A larger sample, perhaps using a survey methodology, would also allow potential additional sociodemographic differences in employment outcomes following SCI, such as sex and work history.^3,4,9 The codes offered in Table 1 might be useful for the construction of such a survey. A further issue relates to the model’s construct of ‘occupation’ and its conceptual overlap with ‘organization’. It would be helpful to examine knowledge and understanding of this model among rehabilitation counselors more broadly and see whether the interpretation of PEO domains differs according to rehabilitation setting (i.e. acute vs. community) and rehabilitation discipline – particularly given the model’s emphasis on implementing interventions within context and environments.^17,18

Limitations

The study would have benefited from including the employers’ perspective in order to identify additional needs and resources required for viable return-to-work planning.³⁷ Our sampling approach, whilst providing breadth and depth across the data, also meant that we did not necessarily include all potentially eligible participants – which we might have done if we were recruiting to saturation rather than purposively, although no new themes were apparent in the data by the final interview.

Conclusions

The findings of this study provide preliminary evidence for the utility of the PEO model as a framework within SCI/D vocational rehabilitation, helping to explain what is required to achieve an individual’s return-to-work goals. Vocational services can align with this model by considering the individual domains and their interactions across time and contexts to facilitate successful employment outcomes for individuals with SCI/D.

Appendix.

Table A1. Interview schedule for persons with SCI/D.

Question	Prompt/s
Can you tell me a bit about your experiences in finding work since your injury?	Previous jobs? Assistance sought (i.e. support services)?
Would you consider using a vocational counseling service?	Why – or why not? What (if any) vocational services have you used?
Do you feel ‘job ready’ at this point?	Why – or why not? What motivates you to find work? What makes it hard for you to get a job?  o employer expectations  o employer’s willingness to modify work role  o personal expectations, e.g. being realistic about own capacity
What sort of supports do you need, or expect, from a vocational counseling service?	Personal? (e.g. social supports) Additional training/education? (i.e. career planning, job matching, CV preparation) Other? (e.g. industry contacts)
Do you have any suggestions about what we can do to facilitate employment opportunities for people with a spinal cord injury?	Most useful aspects about available services? Least useful aspects about available services?

Table A2. Interview schedule for rehabilitation professionals.

Question	Prompt/s
Can you tell me a bit about your experiences in providing vocational support/vocational services for people with a spinal cord injury?	o How do you feel about the available services? o Experience of client contact
What feedback have you had from clients regarding vocational services in general?	o Whether it met their needs o Quality of the service o Wanting more from the service
Please describe your understanding /observations of why clients would use – or not use – a vocational service.	o Willingness/readiness to engage o Understanding of the service o Progress in job preparation/seeking
Do you have any suggestions about what we can do to facilitate employment opportunities for people with a spinal cord injury?	o Most useful aspects o Least useful aspects

Funding Statement

This project was supported by the Lifetime Support Authority of South Australia (submission GA00102).

Disclaimer statements

Contributors None.

Conflicts of interest P. Stewart is employed by the participating organization in this study. The remaining authors have no conflicts of interest to declare.