Employment after spinal cord injury: Relation to selected participant characteristics

737

Employment After Spinal Cord Injury: Participant Characteristics

Relation to Selected

.I. Stuart Krause, PhD, Carol A. Anson, PhD ABSTRACT. Krause JS, Anson CA. Employment after spinal cord injury: relation to selected participant characteristics. Arch Phys Med Rehabil 1996; 77:737-43. Objective: To investigate the relation between selected participant characteristics and employment outcomes after spinal cord injury (SCT).Previous studies produced conflicting results with widely varying employment rates due to differences in study participant characteristics. Design: A field study of the employment history of a large stratified sample of people with SCI. Participants were grouped into cohorts and then compared on several employment variables using the chi square statistic and analysis of variance. Participants: Three hundred sixty-two persons with SCI, selected by stratified sampling according to gender, race, and age. Participants were further grouped into cohorts based on time since injury, injury severity, and years of education. Main Outcome Measures: Multidimensional Adjustment Profile, a specially designed measure of multiple outcomes after SCI. Results: The most successful employment outcomes were obtained by Caucasian women, persons up to the age of 29 years at injury, participants with incomplete injuries, and participants who had completed at least 16 years of education. The least successfuloutcomes were observed in minority men, participants age 50 years or older at injury, persons with complete quadriplegia, and participants with fewer than 12 years of education. Conclusions: Results point to the need for rehabilitation professionals to make special efforts to maximize employability after SC1 among people with biographic characteristics that place them at greatest risk for unemployment. 6 1996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

ETURN to gainful employment, long recognized as a key R indicator of adaptation after spinal cord injury (SCI), was once considered synonymous with rehabilitation success.Nevertheless, for several years the focus of rehabilitation shifted away from gainful employment to other important outcomes. For example, unpaid work, such as volunteering and homemaking, were recognized as important aspects of postinjury life.’ Recently, however, return to gainful employment has regained some of its former status as a primary indicator of rehabilitation success.This shift is probably related to the fact that legislation From the Shepherd Center (Dr. Krause) and the Klemm Analysis Group (Dr. Anson), Atlanta, GA. Submitted for publication August 2, 1995. Accepted in revised form February 14, 1996. Supported by a grant from the Shepherd Center, Atlanta, GA. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or uoon anv organization with which the authors are associated. ’ Reprint re&sts to I. Stuart Krause, PhD, Crawford Research Insticyte, Shepherd Center, 2020 Peachtree Road. NW, Atlanta, GA 30309. 0 I996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/96l7708-3615$3.00/O

such as the Americans with Disabilities Act has been enacted to reduce environmental and cultural barriers that have prevented people with disabilities from reaching their full vocational potential. EMPLOYMENT RATES AFTER SC1 Previous studies have reported widely diverse employment rates after SCI. For instance, a summary of data collected on a large sample of persons from several SC1 centers reported employment rates of only 14% to 28% among subsamples of persons with SC1who were about 5 years postinjury.’ This was a considerable decrease from the 60% total of persons who were working at injury onset. In 1988, Trieschmann’ reviewed more than 20 studies of employment after SC1 and found that reported employment rates ranged from 13% to 48%. She noted that comparisons between such studies were difficult because of differences in study design, such as whether the definition of ‘ ‘employment ” includes student and/or homemaker status, and because of widely diverse subject populations (eg, differences in the amount of vocational training received). Participant characteristics also varied considerably in terms of demographic and injury-related variables in these studies. Further, many of the studies used current employment status as the sole outcome measure, a method that underestimates the actual number of people who return to work, since many people who find employment do not continue to work.4 A more useful approach is to investigate the relation of participant characteristics to a broad range of employment outcomes. PARTICIPANT CHARACTERISTICS AND EMPLOYMENT Research that has correlated employment outcomes with client variables has been limited. These studies have generally either crosstabulated 1 or 2 client characteristics with employment outcomes (for categorical variables such as paraplegic versus quadriplegic) or have calculated mean differences for unemployed and employed participants on continuous variables (eg, age, years of education). For example, age and age at injury onset have consistently been found to be negatively correlated with employment stattr~.~-~ Similarly, several studies have found differences in educational level between employed and unemployed participants.6-‘z One study suggested that postinjury education was particularly important to employment outcomes.” Many of the studies found higher employment rates among participants with paraplegia than among those with quadriplegia.‘,” One study reported that persons with lower cervical lesions (C6 and C7) were more likely to be working than persons with high cervical levels (C5 and higher).8 Other research, however, has failed to find such a relationship.4 Most studies show that although participants with quadriplegia have been reported to be less likely to obtain work, they have been found equally likely to sustain employment.” Three studies that investigated the relation between employment and race all reported higher employment rates among Caucasians than among African-Americans.‘“~“~‘4In the most recent of these studies, James and associates’4utilized a large Arch

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sample from the National Spinal Cord Injury Statistical Center database to identify employment status within the first 6 years after injury. Only individuals between the ages of 16 and 61 who had been employed at the time of injury were selected for the study. James et al found that Caucasian men were more likely than Caucasian women to obtain gainful employment, whereas African-American women were more likely than African-American men to be employed. Educational level was found to be a particularly important predictor of employment among African-Americans. Using a sample of 286 highly educated individuals with SCI, Krause4 examined correlates of postinjury employment. The study design included (1) a sample with an average of 18.6 years since injury (most studies are limited to the first few years after injury), (2) a broad range of employment outcomes, and (3) a cohort method that allowed for the detection of nonlinear relationships between the biographic predictor variables and the employment outcome variables. Krause reported that more than 85% of all participants who were injured for 20 years or more had worked at some point since injury, suggesting that the probability of employment improves dramatically as time since injury increases, and that calculating employment rates at one point in time will lead to underestimates of employability for people with SCI! The findings also suggested that the relation between chronologic age and employment outcomes was not linear; the rate of employment was greatest for people in the 41- to 50-year-old cohort (57%), with a notable decreaseoccurring thereafter. Employment appeared to terminate prematurely among people in the ages 51 to 60 cohort (only 38% employed) rather than in the 6Os, as would be the case with nondisabled people. Lastly, only 3% of individuals with fewer than 12 years of education were employed at the time of the survey, and only 38% had worked at some time since injury. In contrast, approximately 70% of persons with 16 or more years of education were currently working, and nearly all (95%) had worked at some time since injury. The major limitation in this study was the lack of sufficient data among 3 groups of people: women, minorities, and people who were significantly older at injury than the modal person with XI. PURPOSE The purpose of this project was to investigate the relation of several important participant characteristics to critical employment outcomes after SCI. Unlike the previously cited cohort studies that grouped participants into cohorts after data collection, the current study used a stratified sampling technique to select roughly equal numbers of participants in cohorts based on 3 key variables: gender, race, and age at injury onset. The stratified sampling strategy maximized the number of underrepresented groups of women, minorities (nearly all AfricanAmericans), and individuals who were 50 years of age and older at the time of injury. Because this study was initially intended to generate data to extend the findings of the Krause study, many of the cohort variables were identical to those used in that study to allow direct comparability of outcomes.4 METHODS Participants The study sample was selected from inpatient files at a large Southeastern spinal cord injury hospital. Selection criteria were (1) traumatic onset of SCI, (2) 18 years or older at the time of the study, and (3) 2 years or more after injury. All former patients who met the screening criteria were stratified into cohorts based on (1) gender, (2) race (Caucasian and minority), Arch

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and (3) age at injury onset (4 cohorts). Minority participants were almost exclusively African-American (African-American = 117; Native-American = 8; Hispanic = 2). Random samples of approximately 50 individuals were selected from each of the 12 cohorts, with the exception of minority women where a limited number of cases was available. Three hundred sixty-two participants responded to the study (63%). The average age of the sample at the time of the study was 39 years, with an average of 6 years having passed since injury. Fifty-three percent of the sample had quadriplegia (cervical injuries), and 48% had complete injuries. Participants averaged 12.2 years of education, 1.4 years of which were accomplished after the injury. Demographic characteristics differed as a function of gender and race. Caucasian men were the oldest group (both at the time of the study and at the time of injury) followed by minority men, minority women, and Caucasian women. Minority men had the highest percentage of cervical injuries (65%), followed by Caucasian men (56%), Caucasian women (48%), and minority women (29%). Minority women reported the most years since injury (8.0 years), whereas minority men reported the fewest (5.9 years). Caucasian women had the most education (13.6 years), followed by Caucasian men and minority women (12.3 and 12.1 years, respectively). Minority men reported an average of only 10.8 years of education, well below that for any other group. Minority men also reported the least education since injury (lessthan 1 year). In contrast, both minority women and Caucasian women reported more than twice that amount. Procedures The Multidimensional Adjustment Profile (MAP) was mailed to all participants along with one of three other instruments that were not relevant to the current study. A $5 stipend and copies of the descriptive study results were offered to induce participation in the study. Preliminary cover letters were mailed to describe the study prior to the first mailing. Follow-up phone calls were made to nonrespondents, with a second set of materials mailed to all people who agreed to complete materials. Instruments The Multidimensional Adjustment Profile (MAP) was developed specifically for the current study. The instrument is a revised version of the Life Situation Questionnaire (LSQ) that has been used in a 20-year longitudinal study of life after SCI.‘.4,‘5,‘6The MAP contains six subsections,two of which are of interest to the current study: (1) biographic and injury status, and (2) employment history. Seven employment outcomes were utilized for this project: (1) work status at injury, (2) return to the preinjuty job, (3) remaining at the preinjury job, (4) current work status, (5) ever worked since injury, (6) total years worked since injury, and (7) hours per week spent working. Work status during each point in time (at injury, currently, or ever since injury) was defined dichotomously and reflected either selfemployment or work for pay. The number of hours per week spent working included only paid employment activities or selfemployment (not homemaking or volunteering). Data Analysis Both descriptive and comparative data analyses were performed. Descriptive data were generated on all employment variables (ie, means, standard deviations, frequency counts). Participants were grouped into cohorts based on gender, race, injury severity, chronological age, age at injury onset, time since injury, and years of education. Two cohorts were formed for

EMPLOYMENT,

Table

1: Employment

Status

as a Function

Cauacasian Mell

Number of Cases Work status Unemployed Employed Work status at injury Unemployed Employed x*(3, n = 359) = 23.3* Return to same job No Yes Work since injury No Yes x*(3, n = 328) = 15.2’ Years worked since injury Mean Standard Deviation 1=(3,322) = 3.4* Hours per week working Mean Standard Deviation

110

of Gender

Minority Mell

97

SCI,

BIOGRAPHIC

Comparisons

and Race

Caucasian Women

126

STATUS,

Minority Women

30

73% 27%

83% 17%

70% 30%

80% 20%

14% 86%

19% 81%

40% 60%

30% 70%

83% 17%

91% 9%

80% 20%

71% 29%

63% 37%

80% 20%

53% 47%

67% 33%

1.5 2.8

.7 1.8

1.7 2.7

.9 1.9

9.7 17.3

5.9 14.2

11.8 19.4

8.9 18.9

* p < -005. +p< .Ol. * p < .05.

gender and two for race (Caucasian and minority). Injury severity was broken down into four groups based on injury level and whether the injury was neurologically complete (complete quadriplegia, incomplete quadriplegia, complete paraplegia, incomplete paraplegia). Five categories of chronological age and five categories of age at injury onset were defined with roughly IO-year intervals (18 to 30; 31 to 40; 41 to 50; 51 to 60; and older than 60). Participants were divided into three cohorts with regard to years since injury: 2 to 5; 6 to 10; and 11 or more. Lastly, five cohorts were selected based on years of education (fewer than 12 years, 12 years, 13 to 15 years, 16 years, and more than 16 years). Chi square analysis, t test, and analysis of variance (ANOVA) were used to assess the relationships between participant characteristics and employment outcomes. Because of the exploratory nature of the study and the importance of looking at a wide array of employment variables, no statistical correction for multiple tests was employed. If a statistical correction had been utilized across all statistical comparisons, it would have resulted in a lessened power to identify significant findings on the most critical variables (ie, current employment status and ever employed since injury). Additionally, the cohort methodology was selected over multiple regression or other linear techniques to allow the most straightforward and clear interpretations from the data. RESULTS Descriptive Seventy-four percent of the participants were working at the time of injury. At the time of the study, however, only 25% were working. Twelve percent of the participants returned to the same job after their injuries. Of the 44 participants who returned to the same job after injury, slightly fewer than half (n = 20, 45%) were still working at the preinjury job at the time of the study. Thirty-five percent of all participants had been employed at some time since injury. The employed group averaged 4.5 years worked since injury and spent a mean of 37.4 hours per week at work.

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Subsamples Gender and race. Separate analyses were implemented for gender and race, followed by simultaneous analysis of both factors. When analyzing gender separately from race, significant gender differences were observed on two employment variables: (1) employment status at injury, x2 (1,359) = 21.5, p < .OOl, and (2) work since injury, x2 (1,328) = 7.4, p < .Ol. Although women were less likely to be working at the time of injury (84% for men; 62% for women), they were more likely than men to have worked at some time since injury (29% for men; 44% for women). Several significant findings were observed regarding race. Whereas 29% of all Caucasians were currently working, only 17% of the minority participants were currently working (x2 (1,362) = 5.6, p < .05). Forty-two percent of Caucasians had worked at some point since injury, compared with 23% of the minority participants (x2 (1,328) = 11.5, p < .OOl). Similarly, Caucasians were found to be working more hours per week than those in the minority group (10.3 versus 6.5) F(1,357) = 4.1,p

<

Among

.05.

In an analysis using four groups based on a crosstabulation of gender and race (table l), significant differences were obtained on three variables: work status at injury, x2 (3, n = 359) = 23.4, p < ,001; work since injury, x2 (3, n = 328) = 15.2, p < .Ol; and years worked since injury, F(3,322) = 3.4, p < .05. The data present a clear pattern in which Caucasian women report the best outcomes and minority men the worst. Minority women appear to have employment outcomes similar but not equal to those of Caucasian men. Age. Both chronologic age and age at injury were highly correlated with several employment outcomes (tables 2 and 3). Age at injury onset was negatively correlated with four postinjury employment outcomes: (1) current work status, (2) work since injury, (3) years employed since injury, and (4) hours worked per week. The youngest cohort at injury (ages 18 to 30) had the highest current employment rate (32%) and the percentage of currently employed participants declined with Table

2: Employment

Number of cases Work status Unemoloved Empldyed $(df= 4, n = 361) = 14.0* Work status at injury Unemployed Employed $(df = 4, n = 358) = 15.1* Return to same job No Yes Work since injury No Yes x*(4, n = 327) = 21.6’ Years worked since injury Mean Standard Deviation F(4,319) = 4.0’ Hours per week working Mean Standard Deviation F(4.338) = 3.3*

Variables as a Function Age Cohorts

of Chronologic

18-30

31-40

41-50

51-60

61-83

117

107

65

35

37

68% 31%

69% 31%

83% 17%

80% 20%

94% 6%

38% 62%

20% 80%

17% 83%

17% 83%

28% 72%

82% 18

85% 15%

80% 20%

90% 10%

85% 15%

54% 46%

57% 43%

75% 25%

77% 23%

88% 12%

1.5 2.2

2.0 3.2

1.0 2.3

.8 2.1

.2 .6

10.2 16.2

12.6 20.3

7.2 16.7

9.1 18.9

.6 3.5

* p < .Ol. + p < ,005. * p < .05.

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EMPLOYMENT,

Table

3: Employment

Variables

as a Function O-30

Work status Unemployed Employed xZ(4.361)

68% 32%

358)

327)

41-50

Cohorts

51-60

91% 9%

82% 18%

Table

94% 6%

31% 69%

20% 80%

5% 95%

15% 85%

53% 47%

82% 18%

80% 20%

92%

86%

8%

14%

87% 13%

= 21.7'

53% 47%

70% 30%

76% 24%

07% 13%

94% 6%

1.9 2.8

1.1 2.3

1.1 2.3

.I .4

.2 .8

10.9 17.3

9.2 19.0

8.6 17.9

3.5 13.1

= 25.7'

Years worked since injury Mean Standard Deviation Hours per week working Mean Standard Deviation

STATUS,

Krause

5: Employment

Variables

61-75

Work status Unemployed Employed x2(4,

Return to same job No Yes Worked Since Injury No Yes x*(4,

79% 21%

of Age at Injury

= 14.0x

Work status at injury Unemployed Employed x2(4,

31-40

SCI. BIOGRAPHIC

n = 362)

12

91% 9%

of Education

Cohorts

13-15

16

17-20

83% 17%

65% 35%

48% 52%

48% 52%

26% 74%

24% 76%

23% 77%

33% 67%

32% 68%

89% 11%

90% 10%

82% 18%

67% 33%

59% 41%

83% 17%

83% 17%

48% 52%

38% 62%

22% 78%

.5 1.4

.6 1.8

2.1 3.1

2.1 2.3

3.0 2.9

3.9 13.1

4.9 12.1

12.5 19.7

20.0 21.1

19.8 20.4

= 45.0*

Work status at injury Unemployed Employed Return to same job No Yes x'(cff=

as a Function o-11

4, n = 268)

= 15.3'

Worked since injury No Yes x’(df = 4, n = 328) = 66.5* Years worked since injury Mean Standard Deviation Hours per week working Mean Standard Deviation

* p < .Ol. + p < ,001.

* p < .OOl. +p< .Ol.

increasing age as follows: ages 31 to 40, 21%; 41 to 50, 18%; 51 to 59, 9%; and 60 and older, 6%. A similar pattern was noted when employment rates were calculated throughout the entire period since injury. Injury severity. Participants were classified into four groups based on both injury level and completeness of injury (table 4). Significant differences were obtained for work since injury, (x2 (3, n = 304) = 10.1, p < .05) and return to the preinjury job (x’ (3, n = 246) = 12.6, p < .Ol). Overall, participants with incomplete paraplegia reported the most favorable outcomes, whereas participants with complete quadriplegia consistently reported the poorest outcomes. Participants with incomplete paraplegia reported the highest postinjury employment rate (50%) followed by participants with complete paraplegia (43%), participants with incomplete quadriplegia (33%), and participants with complete quadriplegia (26%). Among participants who were working at injury, 20% of the participants with incomplete paraplegia returned to their preinjury jobs, compared

with fewer than 2% of participants who had complete quadriplegia. A supplemental set of analyses compared participants with high cervical (C2 to C4) and low cervical injuries (C5 to C8); no significant differences were identified. Years of education. Cohorts grouped by educational level were associated with dramatically different employment outcomes (table 5). The poorest employment outcomes were observed among the group with the least education (fewer than 12 years) and the best outcomes were observed in the two cohorts with the most education (16 years; more than 16 years). Current employment rates ranged from a low of 9% for people with less than a high school degree to a high of 52% both for people with 16 and people with 17 or more years of education (x2 (4, n = 362) = 45.0, p < .OOl). A similar pattern was obtained when postinjury employment rates were calculated across the entire period of time since injury (x2 (df = 4, R = 328) = 64.5, p < .OOl). Only 17% of each of the two cohorts with the least education had been employed at any time since injury. By contrast, 78% of the most educated group (more than 16 years of education) had been employed at some time after injury. Persons with 16 years of education were a somewhat distant second, at 62%. Cohorts with more years of education were also more likely to return to their preinjury jobs (x2 (df = 4, n = 268) = 15.3, p < .Ol). Forty-one percent of those with some postbaccalaureate education (more than 16 years) returned to the same job after injury, whereas only 11% of people with fewer than 12 years of schooling did so. Similarly, years worked since injury (F(3,323) = 11.7, p < .OOl), as well as hours per week spent working (F(3,354) = 11.2, p < .OOl) were positively correlated with years of education completed. Time since injury. The only outcome that was significantly correlated with time since injury was total years employed since injury (F(2,325) = 16.8, p < .OOl). Participants who had been injured for a longer period of time averaged more years worked since injury.

Table

4: Employment Variables Completeness

as a Function of Injury

of Level

Quadriplegia Complete

Number of cases Work status Unemployed Employed Work status at injury Unemployed Employed Return to same job No Yes x2(3,

n = 246)

Work since No Yes x2(3,

73

Paraplegia

Incomplete 104

Complete

Incomplete

87

70

83% 17%

69% 31%

78% 22%

67% 33%

28% 72%

23% 77%

26% 74%

27% 73%

98% 2%

81% 19%

81% 19%

72% 28%

74% 26%

67% 33%

57% 43%

50% 50%

.9 1.8

1.2 2.4

1.8 3.0

1.8 2.8

6.,7 15.8

11.2 18.9

8.1 16.0

13.5 19.9

= 12.6,

injury

n = 304)

= 10.1+

Years worked since injury Mean Standard Deviation Hours per week working Mean Standard Deviation *p<.o1. + p < .05.

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DISCUSSION The unique contributions of this study were (1) the use of a stratified SC1 sample that included significant numbers of participants who were female, minority, and of older ages at injury; and (2) a cohort methodology that allowed for direct comparisons with previous cohort studies.4.‘4

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60

50 45 40 35 30 25 20 15 10 5 0

50 40 30 20 10 4

< 31 CAUCASIAN MALE

Fig 1. Percentage n , Southeastern

CAUCASIAN FEMALE

employed since study; 0, James

AFRICAN AMERICAN MALE injury as a function and colleagues.

AFRICAN AMERICAN FEMALE of race and gender:

The employment rate at the time of the present study (25%) was within the range cited in previous studies.‘.’ Just as with past research, the employment rate in the present sample was greater (35%) when employment at any time since injury was considered (rather than only employment at the time of the study), but this increase was somewhat modest.4 The postinjury employment rate among this sample represents a substantial decline from the preinjury rate of 74% and points to a clear adverse impact of SC1 on employment among the study participants. Although calculating an overall employment rate clarifies the degree to which a sample is limited vocationally by SCI, the observed employment rate reflects the idiosyncracies of the sample and will therefore differ from study to study. For instance, the present study utilized a Southeastern sample that averaged only 6 years since injury and was not highly educated (32% had not completed high school). These characteristics would be likely to depress the overall employment rates. Confirming the findings of previous research, both gender and race were correlated with employment outcomes in this study.10,“,14 Figure 1 shows a direct comparison of the current findings on employment since injury (Southeastern study) with those of James and colleagues (from the national database).14 The primary difference between the two studies is that Caucasian women had more favorable outcomes than did Caucasian men in the current study, whereas the opposite finding was obtained by James and colleagues.‘4 There are several possible explanations for the higher employment levels among Caucasian women in the present study. First, educational differences between cohorts may have influenced outcomes. In the present study, Caucasian women had the benefit of the highest level of education and the second highest number of years of education since injury. Since educational level, particularly postinjury education, has consistently been found to be the best predictor of postinjury employment, it is likely that employment rates among Caucasian women were related to their educational attainment.6-‘2 Another potential explanation is psychodynamic in nature. Caucasian women were least likely of all cohorts to be working at injury. It is possible that the more entrenched an individual is in a particular job or occupation, the more difficulty that individual may have in shifting careers after SCI. If difficulty of shifting jobs or changing careers is indeed a contributory factor, then it would help to explain why men had less successful postinjury employment outcomes even though they were more likely to be working at the time of injury. More research is needed to examine the effects of career/job entrenchment on postinjury employment

Fig 2. Percentage Minnesota

31 THRU 40

41 THRU 50

51 THRU 60

currently employed as a function study; n , Southeastern study.

> 60

of chronological

outcomes. Finally, low rates of employment in minority cohorts raises the possibility of prejudicial hiring practices as a contributing factor. This question also awaits further research. Both chronological age and age at injury were important correlates of postinjury employment outcomes. Figure 2 shows a comparison of the current employment rate (Southeastern study) with that from the Minnesota study, which utilized a substantially different participant sample (more highly educated, greater time since injury, and fewer minorities).4 A roughly similar pattern of employment was identified in the two studies, albeit with the following differences: the percentage of currently employed participants observed in the present study was considerably lower than that in the previous study, and the decline in the percentage of employed participants with increasing age occurred later in the present study (greater than 60) than in the prior report (51 through 60). Of the three cohort variables that were not used as a basis for sampling in present study, educational level was clearly the most important in relation to employment outcomes. The current study results from the Southeastern study are consistent with those of previous cohort research from the Minnesota study (fig 3). Employment rates increased dramatically with education levels in both the current and the previous reports.’ It is apparent from both studies that individuals with fewer than 12 years of education are at a severe disadvantage vocationally, and that the vocational disadvantage associated with SC1 diminishes greatly with increasing education. The combination of level and completeness of injury appeared to be a better predictor of employment outcomes than injury level alone. These findings point to the importance of looking at more complex measures of injury severity than injury

0 thru 11 Fig 3. Percentage , Minnesota

12

13 thru 15

16

employed since injury as a function study; n , Southeastern study.

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level alone, which was found to be associated with few differences between quadriplegic and paraplegic persons in the present study. Despite the disadvantages inherent in having a more severe injury, however, a substantial number of participants with complete quadriplegia still found and maintained gainful employment. Further, previous research has suggested that people with more severe injuries may take more time after injury and require more education (retraining) to obtain full-time employment than their peers with milder impairment.4 Because the current sample was limited in both time since injury (6 years) and in postinjury education (an average of less than 2 years), it is unlikely that persons with complete quadriplegia had sufficient time to reach their full employment potential. Although time since injury is an important factor that has been both theoretically and empirically linked to employment outcomes after XI, it was not significantly correlated with any employment outcome in the current study, except for years worked since injury.4 The lack of significance of this variable is almost certainly related to the fact that the study sample averaged only 6 years after injury. Similarly, the limited average number of years since injury of the present sample also limited the power of this variable. The results of this study confirm that some groups of people are at greater risk for unemployment after SC1 than others, which clearly has important implications for the rehabilitation of persons with SCI. First, minority men appear to have the greatest difficulty returning to work after SCI, even when they are young and have substantial preinjury employment histories. This finding suggests that special efforts may be needed to help minority men overcome the barriers presented by SCI. Additional attention to retraining would be an obvious start as minority men in this study had actually received lesspostinjury education than any of the other groups. Rehabilitation professionals must also be aware that other kinds of barriers (social or cultural) are likely to contribute to the difficulties of African-American men in obtaining successful vocational rehabilitation outcomes after SCI.‘73’8For example, Alston and McCowan’7 found that a variety of sociocultural factors may adversely affect the rehabilitation process of African-Americans, from inaccurate assessmentdue to inherent cultural biases of tests and/or testers to client characteristics such as a general distrust of the rehabilitation “system,” a tendency not to attempt to answer questions when in doubt, communication difficulties stemming from the use of “Black English” vernacular, and so on. The experience of the Navajo Indians, another minority group that had poor employment outcomes with standard vocational rehabilitation programs, appears to confirm the impact cultural differences can have on rehabilitation outcomes. Several studies concluded that standard VR programs did not take into account the many cultural differences between Navajos and mainstream Americans.‘9~20In response, the Navajo Vocational Rehabilitation Program (NVRP) was created. Directed and staffed by the Navajo themselves, the NVRP eliminated sociocultural barriers and immediately produced a dramatic increase in the employment of its disabled clients.20 A second important conclusion of the present study is that people who are 50 years or older at injury are unlikely to return to work unless they return to their preinjury job. This finding suggeststhat persons in this age range may need special efforts to enhance the probability of return to work. However, given that previous research has shown that a large percentage of people who do return to work after SC1 terminate employment in their 50s expectations for people in this group may need to be reevaluated. Early retirement may be an attractive and viable option for many people in this age group due to the physical rigors of life after SCI. If so, then rehabilitation may be better Arch

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directed towards other avocational pursuits as a valid alternative to gainful employment. Third, women do not appear to be at greater risk for unemployment than men. In fact, women participants in this study attained better employment outcomes than men, although this may be partially explained by the greater amount of education among women participants in this study. Other potential explanations include possible differences in financial resources or in the types of jobs sought or held by men and women. The markedly higher return of minority women to the preinjury job (29%) compared with minority men (9%) may also be a factor in the differential employment rates. Overall, this study pointed to education as the primary requirement for employment, as participants with the most education consistently obtained the most successful employment outcomes. If rehabilitation professionals are fully to address the needs of their clients, they must address broader issuessuch as attendant care, financial disincentives to working, and availability of community resources. Efforts to ensure equal opportunity must include attention to elimination of job discrimination to ensure accessto jobs in line with the individual’s capacity, and assurances that the individual will also reap the rewards of gainful employment, Most participants in the current study were from the Southeastern United States where there has been limited accessto attendant care, accessibleenvironments, and governmental assistance. Geographic location and the associated environment must be considered in any study of employment after SCI. There were two potential limitations to this study. One was its reliance on self-reported data. Although self-report data of straightforward items (eg, date of injury and employment status) is generally reliable, the addition of some objective data from sources such as hospital charts would have helped verify the accuracy of the self-reports. Second, there is always the possibility of sampling bias in self-report studies. Sampling bias has generally been of concern in employment studies when a researcheris attempting to identify an overall “true” employment rate for a given population. In the current study, however, employment outcomes were compared between cohorts in an attempt to identify factors related to employment outcomes, not to ascertain a “true” employment rate. Selective attrition would only be problematic in this study if nonrespondents in one cohort differed systematically from nonrespondents in a different cohort in terms of one of the biographic variables studied. These types of interactions are theoretically possible, but to the authors’ knowledge no such interactions in responsepatterns have been reported in the literature. Future research should focus more on social and cultural barriers that affect employment after SCI. Furthermore, research is needed on innovative employment programs that may assist people in developing the skills needed to return to work after SCI. Lastly, more work is required to determine the impact of the environmental milieu on employment, rather than simply looking for the sources of unemployment within the individual. References 1. Kemp BJ, Vash CL. Productivity after injury in a sample of spinal cord injured persons: a pilot study. .I Chron Dis 191;24:259-75. 2. Stover SL, Fine PR. Spinal cord injury: the facts and figures. Birmingham (AL): University of Alabama at Birmingham, 1986. 3. Trieschmann RB. Spinal cord injuries: psychological, social, and vocational rehabilitation. 2nd ed. New York: Demos Publications, 1988. 4. Krause JS. Employment after spinal cord injury. Arch Phys Med Rehabil 1992;73:163-9. 5. El Ghahit AZ, Hanson RW. Variables associated with obtaining

EMPLOYMENT,

SCI, BIOGRAPHIC

and sustaining employment among spinal cord injured males: a follow-up of 760 veterans. J Chron Dis 1978;31:363-9. 6. DeJong G, Branch LG, Corcoran PJ. Independent living outcomes in spinal cord injury: multivariate analyses. Arch Phys Med Rehabil 1984;65:66-73. I. Dvonch P, Kaplan LI, Grvnbaum BB, Rusk HA. Vocational findings in postdisability employment of patients with spinal cord dysfunction. Arch Phvs Med Rehabil 1965:46:761-6. M. Vocational re-establish8. Geisler WO, jousse AT, Wynnc-Jones ment of patients with spinal cord injury. Med Services J 1966;22: 698-709. follow9. Alfred WG, Fuhrer MJ, Rossi CD. Vocational development ing severe spinal cord injury: a longitudinal study. Arch Phys Med Rehabil 1987;68:854-7. 10. DeVivo MJ, Fine PR. Employment status of spinal cord injured patients 3 years after injury. Arch Phys Med Rehabil 1982;63:2003. 11. El Ghahit AZ, Hanson RW. Educational and training levels and employment of the spinal cord injured patient. Arch Phys Med Rehabil 1979;60:405-6. RT, Freed MM. Vocational development of spinal cord 12. Goldberg injury patients: an g-year follow-up. Arch Phys Med Rehabil 1982; 63:207-10.

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after spinal 13. DeVivo MJ, Rutt RD, Stover SL, Fine PR. Employment cord injury. Arch Phys Med Rehabil 1987; 68:494-g. MJ, Richards JS. Postinjury employment out14. James M, DeVivo comes among african-american and white persons with spinal cord injury. Rehabil Psycho1 1993;38:151-64. 15. Crewe NM, Krause JS. An eleven-year follow-up of adjustment to spinal cord injury. Kehabil Psycho1 1991;35:205-10. age, time since injury, and 16. Krause JS, Crewe NM. Chronologic time of measurement: effect on adjustment after spinal cord injury. Arch Phys Med Rehabil 1991;73:163-9. 17. Alston RJ, McGowan CJ. Aptitude assessment and African American clients: the interplay between culture and psychometrics in rehabilitation. J Rehabil 1994;60(1):44-6. 18. Herbert ST, Cheatham HE. Africentricity and the Black disability experience: a theoretical orientation. J Appl Rehabil Counseling 1988; 1950-54. 19. Miller DL, Joe JR. Employment barriers and work motivation for Navajo rehabilitation clients. Int J Rehabil Res 1993; 16:10717. services for 20. Morgan CO, Guy E, Lee B, Cellini HR. Rehabilitation American Indians: The Navajo experience. J Rehabil 1986;52(2): 25-3 1.

Arch

Phys Med Rehabil

Vol77,

August

1996