Disability and sex/gender intersections in unmet workplace support needs: Findings from a large Canadian survey of workers

Abstract Introduction Individual attributes including disability and sex/gender have the potential to intersect and determine the likelihood of unmet workplace support needs. Our study compares unmet workplace support needs between workers with and without a disability, and according to disability type and sex/gender differences. Methods Workers with (n = 901) and without (n = 895) a disability were surveyed to examine their need and use of workplace supports including job accommodations, work modifications and health benefits. A multivariable logistic model was conducted to examine the relationship between disability status, disability type and sex/gender and unmet workplace support needs. The model included interaction terms between sex/gender × physical disability, sex/gender × nonphysical disability, and sex/gender × physical and nonphysical disability. Results Among participants with a disability, 24% had a physical disability, 20% had a nonphysical disability (e.g., cognitive, mental/emotional or sensory disability) and 56% had both physical and nonphysical disability. Over half of the respondents were women (56%). Results from the multivariable model showed that nondisabled women were more likely to report unmet workplace support needs when compared to nondisabled men (odds ratio [OR] = 1.54, 95% confidence interval [CI], 1.13–2.10). Findings also showed an intersection between the number and type of disability and sex/gender; women with both a physical and nonphysical disability had the greatest likelihood of reporting unmet workplace support needs when compared to nondisabled men (OR = 2.73; 95% CI, 1.83–4.08). Conclusions Being a woman and having one or more disabilities can determine unmet workplace support needs. Strategies to address workplace support needs should consider the intersection between disability and sex/gender differences.


| BACKGROUND
Within the workplace, the supports an employee receives play an important role in addressing the presence of barriers to productive employment. Individual attributes including whether a person has a disability and their sex/gender can determine their experiences in the labor market and the extent to which workplace supports are needed and used. Individual attributes have the potential to intersect and could exacerbate the likelihood of unmet workplace support needs. In a large sample of Canadian workers, our study examines the intersection between disability and sex/gender as they relate to whether workplace support needs are met. Findings will bring to light subgroups who are more likely to face inequities in working conditions. Also, our study will generate insights that can inform practical solutions to support employment for people with and without disabilities.
A body of research indicates that people living with physical and nonphysical disabilities (e.g., mental health, cognitive and sensory disabilities) face challenges in finding and sustaining productive employment compared to their counterparts without a disability. [1][2][3][4][5] Workplace supports modify aspects of the work context that can contribute to employment limitations. 6 Studies indicate that the most-needed workplace supports reported by people with disabilities include health benefits (e.g., prescription drug coverage), work modification (e.g., scheduling flexibility), and job accommodation (e.g., accessible workstations). [6][7][8][9][10][11] People with disabilities also indicate that workplace support needs are often unmet. Within industrialized contexts, studies point to a lack of employer awareness regarding the legal requirement for reasonable accommodations or an understanding of how to adjust the work environment for people with different disabling conditions. 5,6,12 Unmet workplace support needs can also be attributed to difficulties faced by people with disabilities in communicating their requirements at work, reporting a lack of control over their working conditions, apprehension to receive special treatment in comparison to their nondisabled colleagues, or fear of losing career development opportunities. 8,9 Of significance, research also indicates that workplace supports can be beneficial to a range of workers including those who face limitations attributed to child and elder care responsibilities, aging, or pregnancy. [13][14][15][16][17] Accordingly, workers without a disabling health condition may also benefit from similar workplace supports to those required by people with disabilities. Currently, limited research exists which compares the extent to which workers with and without disabilities differ in terms of their need and use of workplace supports.
It is important to highlight that working experiences can differ according to a range of intersecting disability and personal factors. 2 Intersectionality offers a lens to interpret the combined effects of individual identities that cannot be disaggregated or understood separately. 18,19 The application of intersectionality has commonly utilized qualitative methods to examine how people at the nexus of different social identities experience multiple and overlapping challenges in different social domains. Intersectionality underscores one's experiences, context, and intersecting power structures that emerge from macrolevel forces and contribute to advantage or disadvantage within the working world. [20][21][22][23] In studies of people with disabilities, intersectionality has provided deeper insight into the experiences of a heterogeneous population including subgroups who face greater disadvantage or privilege in the labor market. 24,25 In this study we draw from an intersectional framework to examine how disability factors and sex/gender differences can interact to influence unmet workplace support needs.
The number and type of disabilities can determine the likelihood of finding employment, and sustaining productivity. [26][27][28] Some research indicates that nonphysical disabilities (i.e., mental health or cognitive impairments) are associated with significant work functioning restrictions when compared to physical disabilities. 29 These same studies indicate that workers with both a physical and nonphysical disability are more likely to experience challenges within the labor market when compared to those living with either a physical or nonphysical disability alone. 28,29 Few studies have examined how workplace support need and use differs for those reporting different disability types and numbers.
Unmet workplace support needs also has the potential to differ according to sex/gender. Studies highlight differences between women and men based on sex (biology) and gender (sociocultural) in occupation and educational attainment, need for job accommodation, availability of career advancement opportunities, remuneration, productivity, job control, exposure to workplace hazards, and worklife balance. [30][31][32][33][34][35][36] Recent population-level data indicate that disability prevalence is greater among women than men. 3 Men with disabilities more frequently hold paid employment, and are more likely to work full-time hours and earn a higher income when compared to women with disabilities. 3 Growing methodological literature has examined sex and gender measures in work and health research. 37 In the absence of specific measures, taking a more inclusive approach to assessing biological and sociocultural determinants can enable researchers to examine sex/gender differences. 38 For instance, using an open-ended self-report measure that captured dimensions of sex and gender, a recent cross-sectional survey of 463 older men (n = 197) and women (n = 266) with arthritis investigated the availability and need of 14 workplace supports. 38 When compared to participants who were men, women participants more frequently reported needing >5 workplace supports (21% vs. 35%) and having unmet workplace support needs (20% vs. 27%). 38 To elaborate on existing evidence, research of a broader age-range of working adults with and without disabilities is required to compare unmet workplace support needs for women and men. 38

| AIMS AND HYPOTHESES
To date, limited studies of people with disabilities have leveraged quantitative survey data to examine how sex/gender and disability can intersect and influence labor market experiences. 18,25,39 We utilize data from a large community-based survey to compare the likelihood of reporting unmet workplace support needs between people with and without disability. Our study also aims to examine the intersection between disability status and type, and sex/gender and the likelihood of unmet workplace support needs. We hypothesize that: 1. Participants reporting a disability will be more likely to report unmet workplace support needs when compared to their counterparts without a disability.
2. Participants who report living with both physical and nonphysical disability will be more likely to report unmet workplace support needs when compared to those who report living with either a physical or nonphysical disability.
3. Sex/gender will intersect the relationship between disability and unmet workplace support needs, such that the relationship between disability and unmet workplace support needs will be most pronounced for women when compared to men.
4. The intersection between sex/gender and disability and its relationship with unmet workplace support needs will be additive, such that unmet workplace support needs will be most pronounced in women living with both a physical and nonphysical disability when compared to men not living with a disability.
Results have the potential to contribute to recommendations for the design and delivery of policies and programs that promote greater inclusion for people living with disabilities and other workers within the labor market. 40

| METHODS
To test the study hypotheses, an online survey of Canadians with and without disabilities was conducted from July to August 2018. Eligibility criteria included being ≥18 years of age and fluent in English.
To capture working experiences, eligible participants had to hold paid employment for at least ≥15 h/week. Given the challenge associated with recruiting large community-based samples of people with disabilities necessary to test interaction effects in multivariable models, 41 survey participants were identified from an existing panel that is maintained by a research firm. The panel consists of over one million Canadians and is nationally representative according to region and income. 42 Using demographic information held by the research firm, a purposive sampling strategy was utilized to identify potential panel members that met eligibility criteria. Potential participants identified from the panel were contacted and provided information about the study and asked to complete a short screening questionnaire to verify study eligibility. For those who chose to participate, informed consent was obtained, and the online survey was administered. Of the potential participants who viewed the study invitation, met eligibility criteria, and provided consent, 88% completed the survey. To ensure confidentiality, participants were assigned an anonymous identification number, data were stored on a secure server accessible only to the research team, and data were presented in the aggregate form. Study procedures were reviewed by the University of Toronto's research ethics board (REB# 36184).

| Outcome: Unmet workplace support needs
A list of 12 workplace supports including job accommodations (e.g., assistive devices, accessible workplace), work modifications (e.g., scheduling flexibility, modified job duties) and health benefits (e.g., prescription drug coverage, employee assistance program) were presented to participants. Items were drawn from previously published qualitative and quantitative studies of people living with disabilities. 9,11 Unmet workplace support needs were determined by asking participants about their needs and the use of each workplace support. First, participants were asked: "Regardless of whether they were available to you, which of the following benefits, policies or workplace accommodations have you needed in the past year?" (1 = needed, 0 = not needed). Second, participants were asked about their use of each workplace supports using the question: "Regardless of whether they were available to you or whether you needed them, which of the following benefits, policies or workplace accommodations have you used in the past year and how often have you used them?" (1 = used, 0 = not used). A participant was categorized as having unmet workplace support needs when the total number of needed workplace supports exceeded the number of workplace supports used. 10 Notably, our approach enabled us to capture the need and usage of workplace supports that could be formally provided by an employer or infomally accessed by a worker. 10

Disability
Participants were asked about difficulties related to four categories that included physical, cognitive, mental/emotional, or sensory disability. 43 Item response occurred on a four-point scale (0 = no, 1 = sometimes, 2 = often, 3 = always). Participants who reported having sometimes difficulty on at least one item were categorized as having a disability. 43

Sex/gender
Participants were asked an open-ended question to identify their sex/gender. Participants were then categorized as either women, men or nonbinary. We label this variable as sex/gender to account for biological and social dimensions that will be captured by self-report. 38

| Covariates
Sociodemographic factors, health factors, and work characteristics were included in our analysis as covariates and selected according to their relationship with disability and work identified in previous research. 1

Sociodemographic
Information on age (years), educational attainment (1 = primary to high school, 2 = some postsecondary, 3 = graduated postsecondary), marital status, and personal income was collected.

Work characteristics
Information on job sector (business/administration/technology, health/science/teaching, sales/service, and trades/transportation sectors), job tenure (years), hours worked/week and organizational size were collected (e.g., small  45 Limitations were assessed on five dimensions (e.g., time management, physical demands, mental/interpersonal demands, and output) and item response occurred on a four-point scale (0 = none of the time (0%), 4 = all of the time (100%)). Items from each dimension were weighted and summed to produce a total score ranging from 0.4 to 28.6, with a higher score reflecting fewer overall limitations. 45 Lastly, absenteeism was assessed by asking participants about the number of missed work days due to health in the past 3 months.

| Analyses
Descriptive statistics (i.e., frequencies, percentages, means, and standard deviation (SDs)) built a profile of respondents to examine the distribution of study variables. To sustain statistical power for subsequent analytical approaches, participants with nonphysical disabilities were grouped together (e.g., mental/emotional, cognitive and sensory disabilities). χ 2 test and analysis of variance were conducted to examine if study variables differed across four groups including: no disability, physical disability, nonphysical disability and both physical and nonphysical disability.
Univariable logistic models were developed to examine the association between predictor variables, study covariates, and unmet workplace support needs. Separate univariable logistic regression models were conducted for the total sample, those not living with a disability, and those living with a physical, nonphysical disability or both a physical and nonphysical disability. Covariates significantly associated with unmet workplace support needs in at least one group were carried forward to the final multivariable model. Also, variables of theoretical importance in the relationship between disability and unmet workplace support needs or have been associated with sex/ gender differences in employment experiences were carried forward.
A multivariable logistic regression model was conducted which included sex/gender and physical disability, nonphysical disability, and both physical and nonphysical disability as study covariates. The multivariable model also included the interaction terms between sex/ gender × physical disability, sex/gender × nonphysical disability, and sex/gender × physical and nonphysical disability. To enable the comparison of primary independent variables and their interaction effects, the reference category in the multivariable model was set to men not reporting a disability. Model fit was determined using the Hosmer-Lemeshow goodness-of-fit test.

| RESULTS
A total of 1796 employed participants with (n = 895) and without disabilities (n = 901) completed the survey and had minimal missing data. A description of the study participants is provided in Table 1.
Among those living with a disability, 24% had a physical disability, 20% indicated a nonphysical disability, and 56% reported both physical and nonphysical disability. Just over half of the sample were women (56%) and no participants in the study sample identified as nonbinary. A greater proportion of participants with a nonphysical disability (67%) and physical and nonphysical disability (57%) were women when compared to those reporting a physical disability (52%) or no disability (55%). Over half of the full sample were married/ living as if married (57%). An examination of health factors indicated a mean pain score of 2.6 (SD = 2.7) and a mean fatigue score of 3.7 (SD = 2.9) for the full sample. Also, in the full sample, participants indicated mean self-rated health of 3.0 (SD = 1.0). Those living with both a physical and nonphysical disability reported greater mean pain (mean = 4.5, SD = 2.7) and fatigue (mean = 5.7, SD = 2.6) and lower mean self-rated health (mean = 2.4, SD = 0.9) when compared to participants without a disability or those reporting either a physical or nonphysical disability.
A description of work context factors is provided in Table 1.    Table 2).
Frequency of unmet workplace support needs is presented in Figure 1 according to sex/gender differences (Figure 1). Women more frequently reported unmet workplace support needs when compared to male respondents not reporting a disability (45% vs. 33%). Women with a physical disability were more likely to report unmet workplace support needs when compared to men with a physical disability (54% vs. 43%). Additionally, women with both physical and nonphysical disability were more likely to report unmet workplace support needs when compared to their men with both a physical and nonphysical disability (58% vs. 45%) ( Table 2).
At the univariable level (

| DISCUSSION
Workplace supports including health benefits, job accommodations, and work modifications play a critical role in addressing the limitations to employment participation and fostering labor market engagement. Utilizing a large a sample of employed Canadians, our study indicated that those with a disability were more likely to report unmet workplace support needs when compared to their counterparts without a disability. Notably, we examined the intersection between disability and sex/gender to determine those who may be most susceptible to unmet workplace support needs. Findings highlighted the challenges faced by women in the workplace when it comes to having workplace support needs met. Women living with both a physical and nondisability were more likely to report unmet workplace support needs when compared to men. Employer-based policies and programs that encourage access to workplace support are required to meet the needs of people living with disabilities.
Approaches to promoting the utilization of workplace supports that are tailored to women and those living with more than one disability could be beneficial to facilitate employee engagement.
Workplace supports represent an important employer-led strategy to address the challenges that can impact sustained and productive employment. 12 Aligning with previous research, participants in our study required diverse workplace supports to encourage labor market engagement including prescription drug coverage, scheduling flexibility, extended health benefits, modified job duties, and opportunities to informally modify work. [8][9][10][11] Interestingly, the types of workplace support that were most needed were similar for those with and without disabilities. A body of research highlights that workers report personal responsibilities (e.g., child and eldercare responsibility), health-related demands (e.g., attending healthcare appointments), and workplace factors (e.g., interpersonal conflict) that can interrupt employment engagement. [13][14][15][16][17][46][47][48]  needs when compared to those reporting either a physical or nonphysical disability. Past research highlights an additive effect of living with more than one disability on the severity of work limitations. [27][28][29]50 For instance, population-level data from Canada shows that the co-occurrence of physical and mental health disability were significantly associated with role functional impairment and employment participation restrictions when compared to either physical or mental disorders alone. 50 Within the context of our study, having more than one disability type could increase the requirement for workplace supports and may result in unique challenges to accessing workplace supports. Qualitative research is required to unpack the findings from our study to build an understanding of how living with more than one disability contributes to unmet workplace support needs.
In our sample of nearly equal proportions of men and women, we highlighted sex/gender differences in the likelihood of reporting unmet workplace support needs. Findings align with hypothesis two and indicated that study participants who were women, regardless of disability, were more likely to report unmet workplace support needs when compared to their counterparts who were men. Our findings can be explained by a body of previous research which also show that both sex (e.g., prevelance of certain disabling health conditions, symptom severity, and functional limitations) and gender differences (e.g., elder care responsibilities, parenting, work experiences) can determine physical and psychosocial exposures in the work environment and their impact on person-job fit. [30][31][32][33][34][35][36]38 Drawing from previous research, both sex-and gender-based factors may also determine need and use of workplace supports. Of note, our study used a one-item open-ended self-report question to capture sex and gender dimensions. Accordingly, we were unable to tease apart the specific biological or sociocultural differences between men and women that may inform the availability and utilization of workplace supports. 33,35,38 Additional survey research using specific measures for sex and gender could be beneficial to advance the application of a sex/gender-based analytical approach to understand unmet workplace support needs. 51 Nonetheless, our findings point to the importance of considering sex and gender in the design and delivery of programs to address unmet workplace support needs.
Results indicate the intersection between disability status and type and sex/gender. In support of hypothesis three, we found that the likelihood of unmet workplace support needs was greatest for participants who were women living with a disability. The likelihood of unmet workplace support needs was elevated for women living with both a physical and nonphysical disability. 24

CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.

DISCLOSURE BY AJIM EDITOR OF RECORD
Paul A. Landsbergis declares that he has no conflict of interest in the review and publication decision regarding this article.

DATA AVAILABILITY STATEMENT
Aligning with the requirements of our research ethics protocol, data are not shared.