predictors of return to work intention among unemployed

14 Journal of Rehabilitation Volume 82, Number 2

Journal o f Rehabilitation 2016, Volume 82, No. 2, 14-24

Predictors of Return to Work Intention among Unemployed Adults with Multiple Sclerosis:

A Reasoned Action Approach

Jian Li Richard T. RoesslerKent State University, School of Foundations, Independent Rehabilitation Consultant

Leadership, and Administration

Phillip D. Rumrill Jr Mykal LeslieKent State University, Center for Disability Studies Kent State University, Center for Disability Studies

Fangning WangKent State University, School o f Foundations,

Leadership, and Administration

This investigation examined the extent to which components of the reasoned action model predicted the intention to return to work among unemployed adults with multiple sclerosis (MS; N = 381). Examined in a hierarchical regression analysis, four classes of variables (demographic, attitude toward the behavior, subjective norms, and perceived behavioral control) were operationalized from items in a national survey of the employment concerns of Americans with MS. Findings indicated that those most likely to have a greater intention to return to work possessed the following characteristics: African American, having difficulty meeting financial obligations, and not receiving benefits (R2 = .17). Some support was observed for including self-perceived MS severity and support from significant others as part of the model. Implications for rehabilitation counselors include helping unemployed adults with MS counter employment discrimination, learn about benefits and insurance, secure adequate finances for daily living needs, and cope with the debilitating effects of chronic illness and poverty.

The purpose of this study was to examine precursors to the intention to return to work among a sample of unemployed adults with multiple sclerosis (MS). One

promising approach for understanding factors influencing a commitment to resume employment is referred to as the reasoned action model developed by Fishbein and Ajzen (2010).Employment interventions based on such a model of human

Jian Li, Ph.D., Kent State University, P.O. box 5190, 316 White Hall, Kent, OH 44242-0001.

Email: [email protected].

behavior can potentially improve the involvement in the work force of a talented and experienced, but underemployed, group of workers such as people with MS.

Multiple Sclerosis and UnemploymentWith its onset typically occurring in early to middle adult

hood, MS affects people in the prime of life, and no domain of personal or social functioning is impervious to the unpredictable symptoms associated with this neurological disease (Kalb, 2016). The person’s employment status is a frequent casualty of the illness. Although the vast majority of people with MS have employment histories and most were work-

mailto:[email protected]

Journal of Rehabilitation Volume 82, Number 2 15

mg at the time of diagnosis (Roessler, Rumrill, Li, & Leslie,2015) , the onset and continuation of the disease prompt what appears, in all too many cases, to be a premature exit from the labor force.

In fact, a majority of people with MS are no longer working five years post diagnosis, and the overall employment rate for people with MS hovers between 30 and 45 percent (Uc- celli, Specchia, Battaglia, & Miller, 2009). In a review of international literature on MS and employment spanning a ten- year period (2002 - 2011), Schiavolin et al. (2013) found that 59% of adults with MS worldwide were unemployed. Furthermore, an identical jobless figure was reported in a recent national survey of Americans with MS by Rumrill, Roessler, Li, Daly, and Leslie (2015). Stressing that multiple, interacting factors influence the employment rates of adults with MS, Chiu, Chan, Bishop, DaSilva Cardosa, and O’Neill (2013) reported recent data from the NARCOMS (North American Research Committee on Multiple Sclerosis) Patient Registry indicating that the jobless rate for adults with MS was 58%. According to Chiu’s et al. research, higher than typical unemployment rates persist for adults with MS even with the intervention of vocational rehabilitation (VR) services. Only 48% of clients with MS achieved the closed employed status following VR services, which contrasts with the 62% closed employed rate for all VR clients nationwide.

Of particular importance is the social and personal impact that these high unemployment rates have on individuals with MS and society. In the aforementioned national survey by Rumrill et al. (2015), despite the high unemployment rates reported, members of the sample had strong employment and educational records. For example, 98 percent of respondents had employment histories, and 82 percent were still working at the time of diagnosis. In regard to educational background, 98 percent of participants were high school graduates, and 46 percent were college graduates (Rumrill et al.). With MS impacting approximately 450,000 Americans, and an estimated 10,000 new cases identified each year in the US (an incidence rate that has increased steadily over the past 50 years; Murray,2016) , the high rate of attrition from the workforce means that society is losing a great many highly qualified people from the labor market (NMSS, 2016).

From the personal perspectives of individuals with MS, being unemployed negatively affects general quality of life, identity, and self-esteem, along with much needed financial resources and health benefits (Nissen & Rumrill, 2016; Rubin, Roessler, & Rumrill, 2016; Szymanski & Parker, 2010). Leyshon (2012) stressed that employment is an important life role, one that many people with disabilities are committed to maintaining as long as possible for the benefits they gain from working. Moore et al. (2013) and Antao et al. (2013) also pointed out that psychological gains accrue in addition to the material benefits derived from greater household income and access to health insurance and retirement plans. That said, the low 40% rate of labor force participation among Americans with MS (Rumrill et al., 2015) suggests that this experienced and well-trained group of workers is not enjoying the ben

efits of paid employment to the same degree as Americans without disabilities, who, according to the Office of Disability Employment Policy (ODEP; 2016), report a 68% labor force participation rate.

For many years, medical, psychological, allied health, and rehabilitation researchers have sought to understand how to encourage more people with MS to remain engaged in the labor force. Indeed, among people with MS who are unemployed, 75 percent left their jobs voluntarily (Rumrill, Hennessey, & Nissen, 2008), 80 percent believe that they retain the ability to work (Nissen & Rumrill, 2016), and 75 percent say that they would like to re-enter the workforce (Rumrill, 2015). Clearly, the unemployment figures of people with MS reveal a discrepancy between the desire to re-enter the workforce and the actual execution of this planned action. Therefore, it is important to understand factors influencing the intention of people with MS to return to work so that employers and rehabilitation service providers can (a) target retum- to-work services toward those who are most ready to make the effort and (b) intervene on the modifiable characteristics of individuals with MS and their support systems to ensure a stronger intention to return to work.

The Reasoned Action ApproachIn 2010, in their book entitled “Predicting and chang

ing human behavior,” Fishbein and Ajzen (2010) cited multiple studies validating the “reasoned action” understanding of human behavior. Their reasoned action model stipulates that intention mediates behavioral performance and that both are the product not only of demographic characteristics of the person but also of three independent variables: (a) positive or negative attitude toward the behavior, (b) subjective norms or perceived social pressure, and (c) perceived behavioral control. They defined attitude toward the behavior as the extent to which individuals conclude that the behavior does or does not benefit them. Subjective norms refer to their beliefs that significant others either approve or disapprove of the behavior and either do or do not act in the prescribed way. Finally, extent of perceived behavioral control depends on whether individuals believe “that personal and environmental factors ... can help or impede their efforts to carry out the behavior” (Fishbein & Ajzen, p. 20). In combination, these variables influence both the strength of an intention to behave (e.g., return to work) and the probability of implementing the behavior.

Research Question and HypothesisIn this investigation, we evaluated the applicability of

the reasoned action model for predicting intention to return to work among unemployed adults with MS. Discussed in greater detail in the Methods section, we operationalized reasoned action variables using information collected in a national survey of adults with MS (Rumrill et al., 2015) to address the following research question: To what extent do the reasoned action constructs (i.e., demographics, attitude toward the behavior, subjective norms, and perceived behavioral control) contribute to a model for predicting the retum-to-work intention among unemployed adults with MS? It was hypothesized that the resulting prediction model would retain variables rep-


resenting both demographic characteristics and components of the reasoned action model.

MethodParticipants

The data analyzed in this study were gathered in a national survey of the employment concerns of adults with MS from nine National Multiple Sclerosis Society (NMSS) chapters, representing 21 U.S. states and Washington, DC (Rum- rill et al., 2015). The survey instrument contained questions regarding the demographic, disease-related, support system, and psychological variables pertinent to the retum-to-work intentions of adults with MS. The sample for this study consisted of 557 participants with MS who were unemployed, not retired, and at or younger than the age of 65 at the time of the survey. The sample included 118 men (21%) and 435 women (79%). The 9 NMSS Chapters and the twenty-one states represent rural, urban, and suburban areas (26% of respondents indicated that they lived in urban areas, 49% resided in suburban areas, and 25% resided in rural areas). With an average age of 51 (SD = 9.22), most of the respondents were White (73%); other ethnic groups were represented in the sample with African Americans and Hispanic groups being over-sampled (15% were African American; 9% were Hispanic; and 3% were Asian, Pacific Islanders, Native American, or Alaskan Natives). The group was also well educated with 96% being high school graduates and 31% being college graduates.

Illness-related symptoms reported by the group indicated a mixture of severe to non-severe MS conditions, as well as a wide range of physiological, sensory, and psychological effects. Frequently reported symptoms were as follows: fatigue (indicated by 88% of respondents), diminished physical capacity (80%), balance/coordination problems (79%), gait/mobility impairment (70%), cognitive impairment (64%), bowel or bladder dysfunction (62%), numbness (62%), tingling (61%), spasticity (59%), pain (59%), depression (54%), sleep disturbance (51%), vision problems (44%), anxiety (41%), sexual dysfunction (38%), speech problems (27%), tremor (27%), and bipolar disorder (7%).

ProcedureThirteen members of one NMSS chapter in the Midwest

ern United States participated in a working group to assist in developing the survey instrument, which was then reviewed by three experts with extensive experience in MS research. Once the final instrument was developed, we identified nine NMSS chapters representative of diverse geographic areas, living situations (e.g., rural/urban/suburban settings), and racial/ethnic groups to participate in the survey. To increase participation ofNMSS clients from diverse racial/ethnic backgrounds, eight of the participating NMSS chapters were asked to identify stratified random sub-samples of 800 clients and one chapter was asked to draw a stratified random sub-sample of 1,600 clients. The researchers oversampled Hispanic/Lati- no and African American clients within NMSS chapters that had relatively high proportions of these two groups on their client registries. The goal of this sampling procedure was to

ensure that at least five percent of the overall respondent sample consisted of Hispanic/Latino individuals with MS and that at least five percent were African Americans; these proportions are consistent with commonly held estimates of population parameters for people with MS (Minden et al., 2006).

Drawing on Dillman’s (2009) recommendations, the research team implemented several strategies to improve survey return rates. Two weeks prior to mailing the survey, chapter service directors sent a pre-notice letter to those selected for the national stratified sample (N= 8,000). The pre-notice letter explained the purpose of the study and the importance of completing and returning the survey as well as indicating that those selected for the study would receive a survey in approximately two weeks. The survey was then mailed with an explanatory cover letter from a member of the research team; each potential respondent received a paper version of the survey, in either English or English and Spanish depending on his or her identified ethnicity. In that mailing, potential respondents received information pertaining to accessing the survey in an on-line and telephone format offered in either English or Spanish. Four weeks after the survey had been mailed, the researchers provided the chapters with “reminder/thank you” postcards to send to the 8,000 NMSS members participating in the survey. In a final effort to improve survey return rates, each chapter service director sent an e-mail message to each NMSS member with an available e-mail address six weeks after the “reminder/thank you” postcards asking the individual to complete and return the survey. Six hundred thirty-one surveys were returned to participating chapters as undeliverable, reducing the available target sample to 7,369 people with MS. Of the target sample, 1,932 members returned questionnaires, resulting in a response rate of 26%. The sample for this investigation was comprised of 557 respondents who identified themselves as unemployed, not retired, and at or younger than the age of 65.

Measures and VariablesAll data utilized in this investigation of predictors of

retum-to-work intention were collected via a 98-item questionnaire with fixed and open response sets. Sections of the questionnaire that contributed independent and dependent variables to this analysis included demographic characteristics of respondents, disease-related health status, stress coping skills, quality of life, employment concerns, disability benefits, and vocational support services received. The dependent variable, intention to return to work, was an additive composite variable based on two items: return to work eagerness (i.e., a 5-point Likert scale ranging from “1-not eager at all” to “5-very eager”) and return to work readiness (i.e., a 5-point Likert scale ranging from “ 1-not ready at all” to “5-complete- ly ready”). The internal consistency reliability as measured by Cronbach’s Alpha coefficient for return to work intention within the present sample was 0.73. The following paragraphs describe the independent variable sets in this investigation.

Demographic characteristics. Eight demographic variables were adopted for this study, and some were recoded into dichotomous variables for clearer interpretation. These in-


eluded gender (0 = female, 1 = male), racial/ethnic status (1 = White, 2 = African American, 3 = Hispanic/Latino, 4 = other), educational attainment (0 = non-college graduate, 1 = college graduate or higher), current financial status (0 = able to meet expenses, 1 = difficulty meeting expenses), receipt of disability benefits (0 = no Social Security or long-term disability benefits, 1 = Social Security and/or long-term disability benefits), age in years, number of dependent children in the household, and duration of illness in years.

Attitude toward the behavior. The survey contained 38 employment concerns items asking participants to indicate whether they were satisfied (i.e., 0 = unsatisfied, 1 = satisfied) that the concern was being addressed in their work lives and their communities. Seven items out of the 38 were used to measure participants’ attitude toward the intention to return to work. Extent of satisfaction or dissatisfaction on the seven items would indicate whether participants believed that efforts to return to work would benefit them or not. Items used to measure attitude included those suggesting whether respondents were satisfied or dissatisfied with their situations regarding having opportunities for job training or retraining, having qualifications fairly evaluated, being treated fairly in the hiring process, having physical access to workplace facilities, having access to assistive technology resources needed at work, and understanding the risks and benefits of disclosing disability status to employers. The seven items were summed, and the additive composite variable had scores ranging from 0 to 7, with higher scores indicating that participants expected more positive outcomes if they performed the behavior in question, that is, implemented behavior to return to work.

Subjective norms. Four items from the employment concerns survey were used to measure subjective norms, i.e., the extent to which respondents believed that significant others would approve or disapprove of the behavior and the extent to which significant others behaved in accordance with those norms. As applied in this investigation, subjective norms are indicative of the individual’s perception that social influences are supportive of the intention to return to work. Variables used to estimate participants’ beliefs that subjective norms were supportive or not supportive of the intention to return to work included the (a) extent to which participants rated their lives as positive and supportive in terms of the quality of social life (i.e., a 7-point Likert scale ranging from “ 1-totally unsatisfied” to “7-totally satisfied”) and the quality of family life (i.e., a 7-point Likert scale ranging from “ 1-totally unsatisfied” to “7-totally satisfied”), (b) number of relevant support services received since being diagnosed with MS (i.e., state vocational rehabilitation services, MS society or other support group services, and other services such as job training and job placement), and (c) an additive support network variable based on two employment concern items. This support network component incorporated participant ratings of satisfaction with return-to-work support from physicians, significant others, and service providers.

Perceived behavioral control. Perceived behavioral control refers to respondents’ beliefs that their circumstances re

sult in a life outlook of internal or external control. In this study, subjective estimates that physical, emotional, and environmental states are conducive to efforts to implement a personal intention, in this case, return to work, were used to measure perceived behavioral control. Physical state variables (i.e., perceived MS impact) included: presence of cognitive impairments (0 = no, 1 = yes); perceived symptom severity as measured by a three-level categorical variable representing no or little current symptoms that affect daily functioning (1), some symptoms that affect daily functioning (2), and multiple severe symptoms significantly limiting daily functioning (3); and gait/mobility impairment assessed using the Patient-determined Disease Steps (PDDS; Hohol, Orav, & Weiner, 1995) on a 9-point scale ranging from normal (1) to bedridden (9).

Emotional state variables included the extent to which participants’ lives were fulfilling in terms of their expectations and hopes for the future (i.e., a 7-point Likert scale ranging from “1 -totally unsatisfied” to “7-totally satisfied”), satisfaction with being encouraged to take control of one’s own life (0 = unsatisfied, 1 = satisfied), and stress coping skills. Participants’ stress coping skills were measured using the Perceived Stress Scale (Hewitt, Flett, & Mosher, 1992), an 11-item instrument that asks respondents to report how frequently during the previous month they had encountered or dealt with stressful life events. The items were rated on a 5-point Likert scale (i.e., “ 1 = never”, “2 = rarely”, “3 = occasionally”, “4 = often”, “5 = always”). Positively stated items indicate effective coping for a particular type of stressful event (e.g., “How often have you felt that things were going your way?”). The scoring metric for negatively stated items (e.g., “How often have you felt that you were unable to control the important things in life?”) was reversed to indicate effective coping and lower stress levels. The item scores were summed, and the possible range for the scale was 11-55, with higher scores indicating greater coping skills. The Cronbach Alpha coefficient for the Perceived Stress Scale within the present sample was 0.90, which is consistent with findings reported by Hewitt et al.

Environmental state was measured by an additive composite variable based on two items, self-reported satisfaction with access to transportation needed for daily living and self-reported satisfaction with one’s current housing accessibility. Both items were rated on a 5-point Likert scale ranging from “ 1-very dissatisfied” to “5-very satisfied”. The Cronbach Alpha coefficient for the environmental state variable was 0.62.

Statistical AnalysisHierarchical multiple regression analysis was used to

measure the incremental variance accounted for by each predictor set identified in the reasoned action model over and above what was explained by predictors entered at earlier steps in the model. As Cohen, Cohen, West, and Aiken (2003) suggested, demographic variables are good candidates to be entered in the initial step of a hierarchical regression analysis to derive a clearer idea of the explanatory power of a theoretical model. Therefore, a four-block hierarchical regression


model was developed to investigate the extent to which reasoned action constructs contribute to an understanding of the retum-to-work intention of unemployed adults with MS. The four sets or blocks of independent variables were entered into the model sequentially as noted in the research question.

To be specific, the analysis was conducted with the continuous variable return to work intention as the dependent variable and the following four sets of independent variables: (a) step 1 for demographic characteristics: gender, racial/ethnic status, educational attainment, current financial status, disability benefits, age, number of dependent children, and duration of illness; (b) step 2 for attitude toward the behavior: perception of workplace attributes as conducive to returning to work; (c) step 3 for subjective norms: quality of social and family life, number of support services received after MS diagnosis, and retum-to-work support from physicians, significant others, and service providers; and (d) step 4 for perceived behavioral control: presence of cognitive impairments, perceived symptom severity, PDDS, expectations and hopes for the future, satisfaction with being encouraged to take control of one’s own life, stress coping skills, and satisfaction with transportation and housing accessibility. The analysis was conducted using the statistical computer package STATA 12.1 (StataCorp, College Station, TX, 2011), and the alpha significance level for the hypothesis tests was set at .05.

ResultsBefore conducting the analysis, the data matrix was

screened and analyzed for missing data. As is commonly observed in survey research, missing data created some challenges in this study. Specifically, a large group of respondents did not respond to all of the employment concerns items. As a result, missing data occurred pertaining to several of the composite variables considered in this study (e.g., perception of the workplace being conducive to returning to work; retum-to- work support from physicians, significant others, and service providers; satisfaction with being encouraged to take control of one’s own life). Analyses of the missing data showed that the missingness was not independent from some of the variables used in the study. For example, the missingness on the composite variables based on the employment concerns items was associated with participants’ educational attainment (x2 = 5.63, df= 1 ,p < .05), indicating that participants with lower educational levels were less likely to respond to the employment concerns items; the missingness in the entire data matrix in this study was also associated with participants’ financial status (x2 = 5.01, df= l, p < .05), indicating that participants who had difficulty meeting expenses were more likely to provide non-responses on the variables used in this study.

It is also likely that some data were not missing at random. It is possible that the participants who chose not to respond would have provided lower satisfaction or less positive scores if they had chosen to respond to all of the items in this study. Due to the high proportion of missing data and the missing data mechanisms in this investigation, it was decided not to use the missing data treatments based on mod

eling techniques, but to use the traditional listwise deletion approach. The analysis was conducted on the participants who provided complete information on the variables used in this study, which resulted in a final analytical sample size of 381. The sample after deletion may not be representative of the complete data set, which could lead to biased parameter estimates and reduced power. Therefore, caution is warranted when making inferences regarding the generalizability of the findings in this investigation.

Regression assumptions were also investigated through diagnostic techniques in the study. We examined the normality of errors, homogeneity of error variance, and linearity between the independent and dependent variables. We also screened for influential observations and collinearity issues. No severe departures from the regression assumptions were observed; therefore, the model was fitted to the sample data.

This Results section first presents descriptive statistics related to characteristics of the participants for each independent variable and then provides a description of the results of the hierarchical multiple regression analysis. Table 1 exhibits the descriptive statistics related to the categorical independent variables, whereas Table 2 displays descriptive statistics related to the continuous independent and dependent variables. Table 3 displays the results of the hierarchical regression analysis by providing the values of change in R2 (AR2) at each step, unstandardized regression coefficients (B), standard errors associated with the unstandardized regression coefficients, and standardized coefficients (JJ) for the predictor variables at each step when they were newly entered into the model and in the final model.

Demographic characteristics were entered into the regression model in the first step. The eight demographic variables accounted for a significant amount of variance in return to work intention of study participants (R2 = .11, F(l0 370) = 4.61, p < .001). Racial/ethnic status, receipt of Social Security Disability Insurance and/or long-term disability benefits, and current financial status contributed significantly to the explanatory power for return to work intention. Specifically, compared to their Caucasian peers, African Americans had significantly higher return to work intention scores (JJ = 0.11, t = 2.19, p < .05). Unemployed adults with MS had significantly lower return to work intention scores if they received Social Security Disability Insurance and/or long-term disability benefits (JJ = -0.11, t = -2.16, p < .05). Respondents who had difficulty meeting expenses had significantly higher return to work intention scores than those who were able to meet expenses (JJ = 0.13,/ = 2.52, p < .05). In the sample data, male participants had higher return to work intention scores than their female counterparts, and age had a negative relationship with return to work intention; however, the effects of gender and age were only marginally significant.

Attitude toward the behavior as measured by participants’ perceptions of the workplace being conducive or not to returning to work was entered into the model in the second step. The addition of this variable did not yield a significant


increase in variance in return to work intention (R2 = .11, A/?2 = 0.00, F(l 369) = 0.06, p = .81). The standardized coefficient of this variable was not statistically significant, indicating that perceptions of the workplace being conducive or not to returning to work did not independently contribute to the change in variance in return to work intention scores.

Variables for subjective norms, such as quality of social life, quality of family life, number of support services received after diagnosis of MS, and satisfaction with support to

remain employed after diagnosis were entered into the model in the third step. As a whole set, these variables accounted for a significant amount of variance in return to work intention over and above what had been explained by the independent variables entered in the previous two steps (R2 = .14, AR1 = 0.02, F (4 365) = 2.55, p < .05). However, none of the variables in this block individually contributed significantly to the change in variance in return to work intention; their coefficients were not statistically significant. It is noteworthy that the coefficient of quality of social life approached sig

nificance (ft = 0.12, t = 1.87, p = .06), indicating that return to work intention scores would increase, albeit non-significantly, when the quality of social life increased.

Perceived behavioral control as measured by physical, emotional, and environmental state variables was entered into the regression model in the fourth and final step. The addition of these seven variables accounted for a significant amount of additional variance in return to work intention over and above what had been explained by the variables in the previous three steps (R2 = .17, AR2 = 0.04, F 357|= \ .91,p < .05). Self-perceived severity of MS symptoms contributed significantly to the change in variance in return to work intention scores. Those unemployed adults with MS who reported multiple, severe symptoms significantly limiting their daily functioning tended to have significantly lower return to work intention scores compared to their peers who reported no or less severe symptoms (ft = -0.20, t = -2.08, p < .05). In the final model, the three variables that were identified as significant contributors to the variance in return to work intention in the previous steps remained as significant contributors: racial/ethnic status (ft = 0.11, / = 2.13 ,p < .05), receipt of disability benefits (ft = -0.11, / = -2.26, p < .05), and current financial status (ft = 0.18, t = 3 3 2 ,p < .01). The final model accounted for 17% of the variance in return to work intention, which is a moderate effect size according to Cohen’s guidelines (1988).

DiscussionThe research question for this investigation ad

dressed the issue of whether demographics, attitude toward behavior, subjective norms, and perceived behavioral control were significant predictors of retum-to-work intention among unemployed adults with MS. Using a hierarchical regression analysis, data were entered in four steps - demographics, attitude toward behavior, social norms, and perceived behavioral control variables. Demographic variables were entered first to determine the significance of immutable and lifestyle characteristics independent of reasoned action constructs. Reasoned action components were then examined for

Table 1.

Dascrqithv statistics afpuilaj{*mls Jbr ciri&gmcol rndtpsatittni vanabUs (N = 381)

dO EU tetitici N %

Grader

Fm ule 298 7822

Male 83 218

Racnl/ethnir afartuft

White 278 73.0

African Amenrap 58 1521

HjgjBMric/I ̂ rtmn 34 8.9

Other I I 29

FA rM im il atfeunmait

Less than college grathutr 255 66 9

College gnufauiE ix above 126 33.1

Social Security disability m snrv ice/km g-tE vm disability

No 338 88.7

Yea 43 113

G w ent fiom cal ttatna

Able Id meet rapratet 131 34.4

Difficulty meetmg ocpmle* 250 65.6

PteSrare pf a cognitive ant] ui m in i

N d 50 13.1

Yet 331 86 9

Sclf-pei cxrvni te ra ity Df tymptoma

No or lMile attract symptoms 35 91

Sane •fliafr iffert dnty fnnrtionwg 197 51.7

\fehiplp. flevene Symptoms sjgnfinmlly bunting daily149 391

fnmiiuupg

Satiafactinn with rarantHgenigit o f bik«g control one's hfe

DiiadkBed 97 25.5

Satisfied 2*4 74.5


their additive value in the following order: attitude toward behavior, subjective norms, and perceived behavioral control. Results from this investigation provided partial confirmation of the hypothesized relationships between the reasoned action components and retum-to-work intentions, with the greatest support found for several of the demographic variables in the prediction model.

Demographic VariablesThe message in these results is that poverty, in concert

with a severe chronic illness such as MS, is a significant predictor of the intention to return to work. Unemployed individuals with MS who expressed stronger predilections to return to work were African American, currently unable to meet their financial obligations, and not receiving either Social Security Disability Insurance or long-term disability benefits. Past research (Julian, Vella, Vollmer, Hadjimichael, & Mohr, 2008) indicates that African American adults with MS are much less likely to be employed than White adults with MS, which supports the inference that they find it more difficult to secure employment and thus are less likely to have adequate finances to meet the day-to-day costs of living with MS.

Attitude Toward BehaviorIn the reasoned action model, attitude toward behavior,

which was not a significant predictor in this study, refers to the anticipated positive or negative consequences associated with the behavior in question, namely, returning to work (Fishbein & Ajzen, 2010). Because measures of variables in the reasoned action model were adapted from existing survey data, it may be that the survey items selected were too far removed from direct questions about the positive or negative effects of behavior related to returning to work. For example, in this study, participants were asked whether they were satisfied in the past that they (a) had access to opportunities for job training, (b) were treated fairly in the hiring process,(c) had physical access to the workplace, and (d) had access to assistive technology needed at work. The assumption was that they would see returning to work as conducive to receiving those same benefits (i.e., positive consequences) in the future.Though answers to these questions were the best information available, they were somewhat removed from more direct queries as to the positive or negative consequences of returning to work. For example, in a study of active commuting, Ajzen (1991) measured attitude toward the behavior “becoming a more active commuter” using several questions as follows: “active commuting would be very ... satisfying/unsatisfying, energizing/tiring, pleasant/unpleasant.” In efforts to derive measures of

reasoned action components, Kovac and Rise (2011) noted the difficulty of using existing information designed for other purposes rather than more standardized questions such as those in the commuting study. Obviously, answers to questions such as “returning to work would be very ... advantageous/disad- vantageous, pleasant/unpleasant, satisfactory/unsatisfactory” would be better indications of the person’s attitude toward the intended behavior.

Subjective NormsSubjective norms pertain to whether individuals perceive

that significant others would approve or disapprove of the intended behavior and whether or not these reference groups perform the behavior (Fishbein & Ajzen, 2010). Although none of the subjective norm predictors were individually related to the criterion, the block of subjective norms variables was significantly related to intention to return to work. Therefore, some evidence exists confirming the value of subjective norms as an aggregate construct. Survey items in this domain offered insights into whether respondents were satisfied that medical personnel, family members, and friends encouraged respondents to return to work. The nature of these items seemed to parallel measures of subjective norms used in reasoned action type studies. For example, in the active commuting study, Ajzen (1991) asked participants whether significant others would approve or disapprove of the person’s intention to increase active commuting and whether significant others would agree or disagree with the intention to increase active commuting. Past research documents the importance of support networks and the fact that they do not always support persons with MS in their desires to return to work (Johnson et al., 2004); questions framed directly to that effect were included in the survey. It should be noted that measures of quality of

TatdeX

DmxriptivB statistics o f participant J ir continuous varuMas (N = 381)

CJundmUica M in. Max. M SD

Ttrlui n to w h I T i i l w i i m 2.00 1000 426 240

Ag t 20.00 65.00 5123 9.55

N um txiof dcprndai cJuHim 0.00 4.00 0.68 0.99

Duration nf lllnriR 0.00 45.00 15.69 8.83

Attitndp 0.00 7.00 314 2.59

Quality of imml life 0.00 6.00 2 61 168

Quality of family life 0.00 600 327 1.74

N nm t» o f Snppat aenncEfl received 0.00 4.00 0.75 0.70

Support to resnm wiykiyrd i Uft dnpinitm 0.00 2.00 101 0.76

FDDS 100 9.00 5.41 2.04

Expedutmaa n d hopes for the firtine 0.00 6.00 2.48 1.87

Slre&l sltiH i 13.00 5400 33.72 7.87

SitisfartHHi o f tiTBtportatm and htmainy arreotilrility 2.00 10.00 6.93 2.08


life and number of services received also contributed to the overall influence of the subjective norm predictor set, albeit not at the individual item level.

Perceived Behavioral ControlFishbein and Ajzen (2010, p. 20) referred to perceived

behavioral control as the extent to which the person believes he or she has the capabilities to perform the behavior under a number of different circumstances.” Again, survey items allowed for only an indirect measure of perceived self-efficacy regarding the intended behavior of returning to work. For example, participants provided evaluations of the

severity of their cognitive and physical symptoms associated with their MS, their belief that others encouraged them to take control of their lives, their views of the future as personally fulfilling, and their perceptions of their abilities to cope with stressful events in their lives. Again we assumed that these measures closely approximated an overall indication of the person’s belief in his or her ability to achieve a desired goal (i.e., returning to work) under a number of different circumstances. Limited by the available data in the survey, we could not obtain direct measures of perceived behavioral control regarding returning to work such as those in Ajzen’s (1991) study in which participants were asked to evaluate their abilities to be active commuters in the following way: “are you able to do it ... agree/disagree, difficult/ easy”; and “it is up to you ... agree/disagree”. Nevertheless, data pertaining to self-perceived severity of MS did have a significant relationship to the intention to return to work, indicating that those who had a sense of greater perceived control with respect to health issues were more likely to intend to return to work. This finding is consistent with a vast amount of research on MS and employment in which disease severity is a critical factor in whether individuals are able to maintain or resume employment (Julian et al., 2008; Krause, Kern, Homtrich, & Ziemssen,

Table?.

ISmarrhical nrgrtaskm analysisJbr m ixm to trt/ri o f tmempfayod athths with rmdtipim sclmxxas (N = 381)

A t a i r y into model F*h 1 model

V rabie hsR B SE(B) P B SE(B) PStep 1 0.11* 0.11*

Gender 0.51 039 0.09 0.50 030 009

Age -0.03 0.01 -0.11 0.02 0.01 -0.10

African AmHKH 0.76 035 0.11* 0.76 036 0.11*

H k p r if /I itinn -0 65 0.43 -0.08 -0.60 0.44 -0.07

Other 0.80 0.72 0.06 0.68 0.71 0.05

Fdw-Mimal jttjwmintf 034 036 0LO7 030 036 006

NmrfurnfitfpHBAint rihilthnu 0.15 0.12 0.06 0.17 0.12 0.07

Dnuticn of iThteflt -0.02 0.01 -0.08 -0.02 0.02 -0 08

Social Security disability nsnrace/km g-tam

disability-0.81 038 -a il* -0.84 037 -011*

Current f t a n a d status 065 036 0.13* 0.89 037 0.18*

Step 2 O il* 0.00

Attitude -0.01 0.05 -0JJ1 -0.09 0.06 -0.09

Step 3 0.14* 0102*

Quality o f social bfe 017 0.09 0.12 O i l 0.10 008

Quality o f family life 0.06 0.09 0.04 0.07 0.09 0.05

NrnrfaB r f a^ipoft ssviceti recurved 0.01 0.17 0.00 0.06 0.17 0.02

Support to iw iarm H u p tn y e d ulln rh a g n rx n 0.19 0.19 0.06 0.17 0.19 0.05

Step 4 0.17* 0.04*

Prtim ce of a cognitive m p a in ra l -0.06 037 -0.01 -006 037 -0.01

PUDS -0.10 0.07 -0.09 -010 0.07 -0.09

S elf-pacm nl seventy Df Symptoms - S ane

■ayn̂ rfi iTivt that d f r r t ibily f c n d im n iig

Selfpcraaw ii seventy of symptoms - Multiple,

-0.42 044 -0.09 -0.42 044 0 09

severe symptoms s ig n S o m f ly l im it in g daily -1.00 0.48 -030* -1.00 0.48 -030*

finrtintring

ExpectabonS and hopes fin the future -0.05 008 -0.04 -0.05 0.08 -0.04

SaijS&dum with ra im tu jg H iiiw iI nf talcing

control one's life0_14 0.31 0.03 0.14 031 0.03

Stress rajpmf; skills 0.03 0.02 009 003 002 0.09

Sartsfacbra o f transportation wnri htmamg-0.08 0.06 -0.07 -0.08 0.06 -007

accessibility

Hato. * p < .05;


2013; Simmons, Tribe, & McDonald, 2010; Smith & Arnett, 2005; Uccelli et al., 2009).

Implications for Rehabilitation CounselorsSeveral implications for rehabilitation counselors are ev

ident in the findings of this study. First, counselors working with African American adults with MS should explore with them whether any type of discrimination in the workplace, either in regard to acquiring or maintaining employment, has impeded their ability to make a living wage. If that is the case, counselors should inform these clients of their protections under the Civil Rights Act and the Americans with Disabilities Act Amendments Act (ADAAA) and assist them in preparing and filing appropriate allegations of discrimination with the Equal Employment Opportunity Commission. Second, counselors should help adults with MS, particularly African American adults with MS, identify and apply for various types of disability benefits. In some cases, they may need additional information about Social Security Disability Insurance (SSDI) benefits and proper procedures for filing claims for SSDI coverage. In other cases, counselors may need to assist adults with MS in identifying other types of benefits. For example, they may be eligible for Workers’ Compensation if their unemployment resulted from some type of on-the-job injury. They may also have benefits available through a short or long-term disability policy from their employer that they have failed to access. Similarly, if counselors are in the process of helping people with MS return to work, they need to inform the clients of the types of employee benefits available through their new employers.

Finally, this poverty profile has significance for working with adults with MS in terms of providing additional financial support while they are in the process of preparing for and seeking employment. Chiu and colleagues (2013) provided evidence in support of this recommendation, reporting that State VR agency clients with MS who were most likely to acquire employment received, in addition to job placement services, financial support for food, clothing, housing, and transportation. To assist them with the cost of medical services and medications, adults with MS also need help securing health insurance through the Affordable Care Act, Medicare/Medic- aid, and employer-sponsored plans and medication discounts through participating pharmaceutical companies. The effectiveness of the above recommendations depends, of course, on the ability of adults with MS to create and adhere to personal budgets, which underscores the need for financial planning advice from rehabilitation or credit counseling professionals.

Support for an aggregate construct of subjective norms as a predictor of the intention to return to work underscores the importance of the social network. Johnson et al. (2004) stressed the beneficial nature of support by family members and medical personnel with respect to employment but pointed out that too often these individuals see retirement as one form of coping with MS. Fortunately, rehabilitation counselors, another important aspect of this support network, are prepared to play a multifaceted role in helping individuals with severe chronic illnesses maintain employment. Role and

function research over a number of years has clarified the concrete ways in which services from rehabilitation counselors, e.g., affective counseling, vocational assessment, vocational counseling, case management, job development, and placement counseling, foster the intention to return to work among adults with disabilities (Rubin, Roessler, & Rumrill, 2016).

Severity of MS symptoms is one frequent predictor of unemployment among adults with MS (Moore et al., 2013) and, as indicated in the findings of this study, an important predictor of the intention to return to work as well. Certainly this finding underscores not only the need to provide comprehensive medical and physical therapy services to adults with MS but also services directed toward environmental modification to ensure access of home and workplace for adults with MS (Bishop et al., 2013; Honan et al., 2012; VanDenend, 2006). Once again the rehabilitation counselor can play a vital role in helping adults with MS develop and implement rehabilitation plans addressing needs for medical maintenance services, home modifications, and on-the-job accommodations.

LimitationsSeveral limitations of the current study are worthy of

consideration. For a better test of the reasoned action model, more direct measures of the component variables are needed. Kovac and Rise’s (2011) recognition of the difficulty of using non-standardized measures of the reasoned action model applies to this study as well. No measure of attempts to return to work was available, thus making it impossible to study the predictive value of the model for actual behavior and to determine the predictive gap between intention and behavior (Hag- gar & Luszczynska, 2014). In addition, although the overall respondent sample of 1,932 individuals appears similar to known population parameters of Americans with MS in terms of demographic characteristics, health status, and labor force participation, the low survey return rate (26%) does limit our warrant for a claim of external validity. It is possible that unemployed, non-retired people with MS at or below retirement age who were among the 74 percent of the original target sample who did not participate in the survey are characteristically different from the 557 people meeting the selection criteria for this analysis who did return surveys.

Other acknowledged limitations of this study include the use of single-item measures for most of the independent variables, the complete reliance on self-report information as indicators of all study variables, the relatively high proportion of missing data on the employment concerns items, and the fact that the additive composite dependent variable comprising dimensions of eagerness and readiness to return to work must be viewed as a partial proxy for return to work intention. Finally, it should be noted that findings from this American sample of unemployed people with MS may not generalize to other countries due to international and intercultural differences in disability policy, workforce development, and vocational rehabilitation services for people with disabilities.


ConclusionThe overriding message of this study is that poverty is a

central part of the life experience of unemployed adults with MS, particularly African American adults with MS who are unable to meet their financial obligations and who have not accessed disability or insurance benefits. Based on results of the study, this profile of poverty is the driving force behind the intention to return to work for adults with MS who are currently unemployed. By the same token, evidence of the predictive value of aspects of the reasoned action model provide a basis for arguing for the importance of social norms (support from significant others) and perceived behavioral control (self-evaluated severity of MS), even though the difficulty of adapting non-standardized measures of the reasoned action constructs was one of the shortcomings of the investigation.

Rehabilitation counselors can take many positive steps to address the needs of unemployed adults with MS. Counselors can help unemployed individuals with MS explore the impact of discrimination on their work situation whether due to racial/ethnic or disability status and take necessary steps to utilize protections in the Civil Rights Act and the ADAAA. Counselors can assist individuals in identifying sources of financial support through major benefit programs such as Social Security, short and long-term disability insurance, Workers’ Compensation, health insurance, and pharmaceutical discounts. They can help individuals develop and implement workable budgets so that they are better able to meet their financial obligations. Finally, they can ensure that vocational rehabilitation plans include adequate maintenance support for housing, food, clothing, and transportation while individuals are involved in medical, vocational training, and job placement aspects of their rehabilitation plans.

Author NoteThis research was funded through a Health Care Delivery and Policy Research grant from the National Multiple Sclerosis Society, New York, NY. The authors wish to thank the National Multiple Sclerosis Society, its participating chapters, and the study participants for their support and assistance with this research.

ReferencesAjzen, I. (1991). The theory of planned behavior. Organiza

tional Behavior and Human Decision Processes, 50, 179-211.

Antao, L., Shaw, L., Ollson, K., Reen, K., To, F., Bossers, A., & Cooper, L. (2013). Chronic pain in episodic illness and its influence in work occupations. Work: A Journal o f Prevention, Assessment, and Rehabilitation, 44, 11-36.

Bishop, M., Roessler, R., Rumrill, P., Frain, M., Woletich, B., & Umeasiegbu, V. (2013). The relationship between housing access variables and employment status among adults with multiple sclerosis. Journal o f Rehabilitation, 79(4), 4-14.

Chiu, C., Chan, F., Bishop, M., da Silva Cardoso, E., & O’Neill, .1. (2013). State vocational rehabilitation services and employment in multiple sclerosis. Multiple Sclerosis Journal, 19( 12), 1655-1664.

Cohen, J. (1988). Statistical power analysis fo r the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum.

Cohen, J., Cohen, P., West, S.G., & Aiken, L.S. (2003). Applied multiple regression/correlation analysis for the behavioral sciences (3rd ed.). Mahwah, NJ: Lawrence Erlbaum.

Dillman, D.A., Smyth, J.D., & Melani Christian, L. (2009). Internet, mail, and mixed-mode surveys: The tailored design method (3rd ed.). Hoboken, NJ: Wiley.

Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. New York: Psychology Press.

Haggar, M., & Luszczynska, A. (2014). Implementation intention and action planning interventions in health contexts: State of the research and proposals for the way forward. Applied Psychology, Health, and Well Being, (5(1), 1-47.

Hewitt, P., Flett, G., & Mosher, S. (1992). The Perceived Stress Scale: Factor structure and relation to depression symptoms in a psychiatric sample. Journal o f Psychopathology and Behavioral Assessment, 14(3), 247-257.

Hohol, M., Orav, E., & Weimer, H. (1995). Disease steps in multiple sclerosis: A simple approach to evaluate disease progression. Neurology, 45, 251-255.

Honan, C., Brown, R., Hine, D., Vowels, L., Wollin, J., Simmons, R., & Pollard, J. (2012). The Multiple Sclerosis Work Difficulties Questionnaire. Multiple Sclerosis Journal, 18, 871-880.

Johnson, K., Yorkston, K„ Klasner, E., Kuehn, C., Johnson, E., & Amtmann, D. (2004). The cost and benefits of employment: a qualitative study of experiences of persons with multiple sclerosis. Archives o f Physical Medicine & Rehabilitation, 85(2), 201-209.

Julian, L.J., Vella, L., Vollmer, T„ Hadjimichael, O., & Mohr, D.C. (2008). Employment in multiple sclerosis. Exiting and re-entering the work force. Journal o f Neurology, 255(9), 1354-1360.

Kalb, R. (2016). Living with multiple sclerosis: The psychosocial challenges for patients and their families. In B. Giesser (Ed.), Primer on multiple sclerosis, 2"£, edition (pp. 483-498). New York: Oxford University Press.

Kovac, V., & Rise, J. (2011). The role of desire in the prediction of intention. Swiss Journal o f Psychology, 70, 141-148.

Krause, I., Kern, S., Homtrich, A., & Ziemssen, T. (2013). Employment status in multiple sclerosis: Impact of disease-specific and non-disease-specific factors. Multiple Sclerosis Journal, 79(13), 1792-1799.

Leyshon, R. (2012). Narrative reflections on occupational transitions. Work: Journal o f Prevention, Assessment & Rehabilitation, 41(1), 109-110.

Minden, S., Frankel, D., Hadden, L., Perloff, J., Srinath, K., & Hoaglin, D. (2006). The Sonya Slifka Longitudinal


Multiple Sclerosis Study: Methods and sample characteristics. Multiple Sclerosis, 12, 24-38.

Moore, P., Harding, K.E., Clarkson, H., Pickersgill, T.P., Wardle, M., & Robertson, N.P (2013). Demographic and clinical factors associated with changes in employment in multiple sclerosis. Multiple Sclerosis Journal, 79(12), 1647-1654.

Murray, T.J. (2016). The history of multiple sclerosis: From the age of description to the age of therapy. In B. Giesser (Ed.), Primer on multiple sclerosis, 2nd edition (pp. 3-10). New York: Oxford University Press.

National Multiple Sclerosis Society. (2016). MS prevalence. New York: National Multiple Sclerosis Society. Available from: http://www.nationalmssociety.org/ About-the-Society/MS-Prevalence.

Nissen, S., & Rumrill, P (2016). Employment and career development considerations. In B. Giesser (Ed.), Primer on multiple sclerosis, 2nd edition (pp. 499-514). New York: Oxford University Press.

ODEP. (2016). Office o f Disability Employment Policy. Retrieved from http://www.dol.gov/odep/

Roessler, R., & Rumrill, P. (2015). Enhancing productivity on your job: The ‘win-win ’ approach to reasonable accommodations. New York: National Multiple Sclerosis Society.

Roessler, R., Rumrill, P, & Fitzgerald, S. (2004). Predictors of employment status for people with multiple sclerosis. Rehabilitation Counseling Bulletin, 47(2), 97- 103.

Roessler, R.T., Rumrill, P.D., Li, .1., & Leslie, M.J. (2015). Predictors of differential employment statuses of adults with multiple sclerosis. Journal o f Vocational Rehabilitation, 42(2), 141-152. doi:10.3233/JVR- 150731

Rubin, S.E., Roessler, R.T., & Rumrill, P.D. (2016). Foundations o f the vocational rehabilitation process (7'h ed.). Austin, TX: Pro Ed.

Rumrill, P.D., Jr. (1996). Employment issues and multiple sclerosis. New York, NY: Demos.

Rumrill, P. (2015). Issues in career development and vocational rehabilitation for people with multiple sclerosis. Rehabilitation Research, Policy, and Education, 29(2), 106-108.

Rumrill, P., Hennessey, M., & Nissen, S. (2008). Employment issues and multiple sclerosis (2nd Edition). New York: Demos.

Rumrill, P, Roessler. R., & Fitzgerald, S. (2004). Vocational rehabilitation-related predictors of quality of life among people with multiple sclerosis. Journal o f Vocational Rehabilitation, 20, 155-163.

Rumrill, P, Roessler, R., Li, J., Daly, K., & Leslie, M. (2015). The employment concerns of Americans with multiple sclerosis: Perspectives from a national sample. Work: A Journal o f Prevention, Assessment, and Rehabilitation, 52(A), 735-748.

Schiavolin, S., Leonardi, M., Giovannetti, A.M., Antozzi, C., Brambilla, L., Confalonieri, P, Confalonieri, P, & Raggi, A. (2013). Factors related to difficulties

with employment in patients with multiple sclerosis: A review of 2002-2011 literature. International Journal o f Rehabilitation Research, 36(2), 105-111. doi: 10.1097/MRR.0b013e32835c79ea

Simmons, R.D., Tribe, K.L., & McDonald, E.A. (2010). Living with multiple sclerosis: Longitudinal changes in employment and the importance of symptom management. Journal o f Neurology, 257(6), 926-936.

Smith, M.M., & Arnett, PA. (2005). Factors related to employment status changes in individuals with multiple sclerosis. Multiple Sclerosis Journal, 11(5), 602-609.

StataCorp. (2011). Stata Statistical Software: Release 12. College Station, TX: StataCorp LP.

Szymanski, E., & Parker, R.M. (2010). Work and disability: Contexts, issues, and strategies for enhancing employment outcomes for people with disabilities. Austin, TX: Pro-Ed.

Uccelli, M., Specchia, C., Battaglia, M.A., & Miller, D.M. (2009). Factors that influence the employment status of people with multiple sclerosis: A multi-national study. Journal o f Neurology, 256(12), 1989-1996.

VanDenend, T. (2006). Employment needs of people with multiple sclerosis: A review of literature and application to occupational therapy practice. Occupational Therapy and Health Care, 20( 1), 61 -77.

http://www.nationalmssociety.org/

http://www.dol.gov/odep/

Copyright of Journal of Rehabilitation is the property of National Rehabilitation Associationand its content may not be copied or emailed to multiple sites or posted to a listserv withoutthe copyright holder's express written permission. However, users may print, download, oremail articles for individual use.

predictors of return to work intention among unemployed

Documents