Rural Disability and Rehabilitation

Research Progress Report #24

 

Linking Health, Secondary Conditions and Employment Outcomes

July, 2004

Health is important to securing and maintaining employment, but for many low-income or unemployed people access to health promotion programs is limited.This is a problem for many people with disabilities who do not work and who rely on Medicare or Medicaid to cover their healthcare costs. Without access to programs that promote health and reduce secondary conditions, people with disabilities may find it difficult to get a job or stay employed. This may be a factor in this group’s persistently high unemployment rates.

Participation in worksite health promotion programs has been shown to (1) increase employee productivity through reduced absenteeism rates, and (2) reduce health-related insurance claims (Aldana, 2001; Pelletier, 2001). Evidence further suggests that worksite health promotion is most beneficial for individuals with multiple health risk factors (Aldana, 2001) that parallel many of the most prevalent secondary conditions experienced by people with disabilities. Some of these risk factors include weight problems, sedentary lifestyle, high blood pressure, and elevated cholesterol.

Secondary conditions occur as a result of, or in conjunction with, a primary disabling condition; and most secondary conditions are amenable to health promotion activities (Ravesloot, et al., 2003). Past research conducted by RTC: Rural has shown that participation in the Living Well with a Disability health promotion program reduced the prevalence of secondary conditions by an average of 25%; significantly increased healthy behaviors such as exercise and proper nutrition; and reduced acute health care expenditures (Ravesloot, et al., 2003). This research, however, did not address the relationship between health promotion and employment. This brief report provides a preliminary look at the relationship among health behaviors, secondary conditions, and employment outcomes for people with disabilities.

Research Methods: The data analyzed for this report came from the 2002 Behavioral Risk Factor Surveillance System (BRFSS), a national data collection effort supported by the Centers for Disease Control. The study sample included 3,094 working age (18-65) people with disabilities, who reported being either “employed” (employed for wages or self-employed) or “not employed” (out-of-work or unable to work).

Data were analyzed using logistic regression. Regression, in the broadest sense, uses independent variables (such as age, education, and gender) to help explain the variation in a dependent variable (i.e. income level). One advantage of regression analysis is that the influence of multiple independent variables on the dependent variable can be evaluated simultaneously. Logistic regression is a type of regression analysis where the dependent variable can take only one of two values (in this case, “employed” vs “not employed”).

This logistic regression model used independent variables measuring age, education, gender, marital status, children, severity of disability, secondary conditions, and health behaviors to predict the probability that an individual will be “employed” versus “not employed.”

Results: From the estimated model, each person is assigned a probability based on individual characteristics. Any person with an estimated probability of employment less than .5 is classified as “not employed” and any person with an estimated probability of .5 or greater is classified as “employed.” Overall, the logistic regression model correctly classified 78% of the sample as “employed” versus “not employed.” Statistically, this represents good model fit with the data.

The probability of being employed was higher for younger, more-educated, and married respondents. Conversely, people who experienced more significant disabilities had a lower probability of employment. These findings were expected and support past research. Of more interest is that after accounting (or controlling) for the influence of age, education, and severity of disability, both health behaviors and secondary conditions further explained the probability of employment. Holding all else constant, respondents who exercised in the previous month had an 8.4 percentage point higher probability of employment compared to respondents who did not exercise, and a one day decrease in average reported days of limitation per month from secondary conditions (ranging from 0 to 30 days per month), increased the probability of employment by 1.3 percentage points. These findings have important implications for the role of health promotion activities in facilitating employment for people with disabilities.

Study Implications:To clarify the implications of these results, consider three individuals who hypothetically enter a health promotion program. Table 1 describes these participants at baseline and post-intervention. The baseline descriptions are based on three individuals from the BRFFS study sample. The associated probabilities for employment are the logistic regression probability estimates for these individuals. 

Post-intervention probabilities were adjusted to incorporate probable changes in health status after participation in a health promotion program such as Living Well with a Disability. For purposes of illustration, it is assumed that individuals will experience a 25% decline in limitation due to secondary conditions and will begin an exercise program if they did not exercise at baseline. Although some participants may not realize a change in work status, it is expected that most program participants would increase their overall probability for employment.

The results described in Table 1 are especially relevant for participants who have a probability near .5 at baseline. At this .5 probability, the expectation of being employed is about 50/50, similar to flipping a coin and predicting heads or tails. If participation in health promotion programming can influence these odds in favor of employment, this will be realized in higher employment rates for individuals with disability.

Results of this study support the hypothesis that participation in health promotion programs (such as Living Well with a Disability) has a positive effect on employment outcomes. Unfortunately, access to health promotion can be significantly limited for people with disabilities who do not work or can’t afford to pay the out-of-pocket costs of health promotion interventions.

One way to overcome this access issue is to incorporate health promotion into the service systems that help people (1) find and maintain work (i.e. Vocational Rehabilitation), and (2) address their ongoing health needs (i.e. Medicaid/Medicare).

Description of Table 1.  Participation in a Health Promotion Program: Potential Impacts on Employment.

Before Participation in a Health Promotion Program

After Participation in a Health
Promotion Program

Participant Description Baseline Probability for Employment Employed at Baseline? Health and Lifestyle Changes Post-intervention Probability for Employment Employed?
Case 1: A 39 year old female with a high school education who experiences moderate disability reports an average of 14 days of limitation due to secondary conditions (out of 30). She currently does not exercise. .476

No

Participant reduces days of limitation by 3.5 days and begins an exercise program.  This reflects a 4.5 percentage point increase in probability  for employment from reduced limitation due to secondary conditions and an 8.4 percentage point increase for starting a regular exercise program. Converting 4.5 and 8.4 percentage points back to probabilities, the post-intervention probability is .476 + .045 +.084 = .605

Yes

Case 2: A 49 year old male with a college education who experiences significant disability reports an average of 22 days of limitation due to secondary conditions (out of 30).  He currently does not exercise. .165

No

Participant reduces limitation by 5.5 days and begins an exercise program.  The reflects a 7.2 percentage point increase in probability for employment from reduced limitations due to secondary conditions and an 8.4 percentage point increase for participating in a regular exercise program. Converting 7.2 and 8.4 percentage points back to probabilities the post-intervention probability is .165 + .072 + .084 = .321

No

Case 3: A 41 year old male with a high school education who experiences moderate disabilities reports an average do 6 days of limitation due to secondary conditions (out of 30). He currently exercises. .682

Yes

Participant reduces limitation by 1.5 days. This reflects a 2.0 percentage point increase in probability for employment from reduced limitation due to secondary conditions. Converting 2.0 percentage points back to probabilities the post-intervention probability is .682 + .02 = .684

Yes

 

Recommendations:

VR offers an array of services including vocational evaluation, counseling and guidance, medical and psychological services, training, and job placement to help people with disabilities find and maintain employment. However, medical services focus on acute care and are constrained to the “diagnosis and treatment of physical or mental impairments.” The Rehabilitation Act language should be modified to specifically reference health promotion programs as a legitimate VR medical expense.

Similarly, while Medicare and Medicaid programs cover some preventive screening, medicine, and immunization services, most health education and wellness programs that focus on behavior change are not reimbursable (Gordon & Lapin, 2001). If Medicare and Medicaid programs cover health promotion interventions, it is likely that people with disabilities will increase their utilization of these types of programs and subsequently realize the associated health benefits. Another probable benefit is that acute medical claims will be reduced.

Next Steps: This study examined the relationship among secondary conditions, health behaviors and employment using cross-sectional BRFSS data. Longitudinal studies that examine employment outcomes as a result of participation in health promotion programs will provide a more complete picture of these interactions. If outcomes from longitudinal studies are confirming, health promotion should be incorporated into the agencies and programs that support the health, well-being and employment of people with disabilities .

References:

Aldana, S.G. (2001). Financial impact for health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion, 15, 296-320.

Gordon, C., & Lapin, P. (2001). A government perspective: If there is so much proof, why is Medicare not rapidly adopting health promotion and disease prevention programs? American Journal of Health Promotion, 15, 383-387.

Pelletier, K. (2001). A review and analysis of the clinical- and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1998-2000 update. American Journal of Health Promotion, 16, 107-116.

Ravesloot, C., Seekins, T., Ipsen, C., et al. (2003). A cost-effectiveness analysis of a community-based health promotion intervention for adults with mobility impairments. Missoula: The University of Montana Rural Institute.

For more information, contact:

Meg Traci, Director  matraci@ruralinstitute.umt.edu
Montana Disability and Health Program
The University of Montana Rural Institute
52 Corbin Hall, Missoula, MT 59812-7056
888-268-2743 toll-free;
406-243-5467 Voice;
406-243-4200 TTY
406-243-2349 (fax)
http://rtc.ruralinstitute.umt.edu
http://mtdh.ruralinstitute.umt.edu

Opinions expressed are those of the authors, and not necessarily those of the funding agencies.
This report is available in Braille, large print and text formats on request.