Rural Disability and Rehabilitation

Research Progress Report #31


Working Well with a Disability: Project Update

November 2005

People with disabilities have significantly lower employment rates than people without disabilities (Harris Interactive, Inc., 2004). One possible contributor to this disparity is that primary disabling conditions place people at greater risk for secondary health conditions, which may undermine their ability to secure or maintain employment. Secondary conditions refer to preventable conditions that occur as a result of, or in conjunction with, a primary disability. For instance, a primary disability such as spinal cord injury may increase risk for several secondary conditions, including pain, pressure sores, urinary tract infections, weight problems, and depression.

Many secondary conditions are either preventable or manageable. Our research on the Living Well with a Disability health promotion program, delivered by Centers for Independent Living (CILs) to their consumers, found that participants reported fewer secondary conditions and reduced medical costs after completing the Living Well workshop (Ravesloot, Seekins, & White, 2005). Likewise, evaluations of work site health promotion programs have found that participation enhanced employee productivity (through decreased absenteeism rates) and decreased insurance claims (Aldana, 2001; Pelletier, 2001). Unfortunately, people with disabilities who are not employed lack access to work site health promotion programs and disposable income to pay for community based health promotion activities.

One strategy to overcome these barriers is to incorporate health promotion activities into a Vocational Rehabilitation (VR) setting. Any expansion of VR services, however, requires hard evidence about effectiveness in terms of vocational outcomes. This research is the first step toward building evidence on the relationship between health and employment for people with disabilities.

Our research hypotheses include:

  • The most significant secondary conditions involve issues related to depression, physical conditioning, weight, and similar factors that are responsive to health and wellness interventions.
  • Higher rates of secondary conditions will be associated with decreased rates of employment outcomes or long-term employment.
  • Higher rates of secondary conditions will be associated with decreased completion rates for VR training, education, and other services.
  • Individuals who engage in healthful behavior will experience improved employment and quality of life outcomes.
  • VR consumers in rural areas will report more secondary conditions and greater limitations due to secondary conditions than their urban counterparts.

 Methods and Approach

RTC: Rural is exploring causal relationships among secondary conditions, health promoting lifestyle behaviors, and employment outcomes through longitudinal data collection. During the spring and summer of 2005, VR counselors in ten states identified and recruited 264 newly-eligible clients to provide longitudinal data about their health and vocational outcomes. The longitudinal data collection consists of four surveys delivered at 6-month intervals to learn if health antecedents are associated with employment and vocational outcomes. Baseline data have been collected on the prevalence and incidence of secondary conditions, limitations to activities of daily living, health promoting lifestyle behaviors, and subjective ratings of quality of life. In 2006, subsequent surveys will include additional questions about progression through VR services and associated employment outcomes.

Research Findings

Although they cannot address our research hypotheses, the baseline data are important to our understanding of how this sample of VR clients compares to past participants of the Living Well health promotion program. If the groups have equivalent health profiles, we might expect to see similar outcomes from participation in a VR-based Living Well health promotion program. Alternately, if the groups have significant differences, this may help inform researchers on modifications to the Living Well curriculum to make it appropriate for a VR group.

Table 1 compares baseline demographic information for the VR sample (n = 264) with baseline demographic information for a national sample of Living Well participants (n =246) recruited from Centers for Independent Living (CILs). There were strong similarities between the VR and CIL groups regarding age, race, and marital status. The majority of participants in both groups also had some college education.

Table 1: Demographic Comparisons  Description of Table 1

VR (n=264) CIL (n=246)
 Age 43.2 years 45.4 years
 Gender 52.3% female 64.3% female
 Married 40.3% 36.6%
 Caucasian 79.8% 82.4%
 African American 13.0% 16.2%
 Employed (part/full-time) 30.5% 16.2%
 Insurance Coverage*
No Health Insurance

*Please note: Many individuals participate in multiple insurance programs.


At baseline, the CIL sample reported higher ratings of private insurance coverage and Medicaid and Medicare enrollment. Almost one-third of VR clients (29.7%) did not have any health insurance coverage versus 3.3% for the CIL sample. This difference should be considered when exploring potential reimbursement models for health promotion programming. For individuals receiving CIL services, reimbursement through health insurance programs may be a better solution than it would be for VR clients.

The two groups reported similar rates of secondary health conditions at baseline. Respondents indicated the degree of limitation from certain secondary conditions on a scale where 0 = no limitation, 1 = mild limitation (1-5 hours per week), 2 = moderate limitation (6-10 hours per week), and 3 = significant limitation (more than 11 hours per week). Aggregating the ratings for 29 secondary conditions (with a possible range of 0 to 87), the average score was 23.5 for the VR sample and 24.1 for the CIL sample. Group means were not statistically different. Additionally, nine of the ten most problematic secondary conditions at baseline appeared in both samples.

Table 2 reports on the top ten secondary conditions for the VR and CIL samples and compares the average severity ratings for each condition. With the exception of mobility issues, the VR sample reported higher limitation ratings for the top ten secondary conditions than the CIL sample. This speaks to the importance of health promotion programming within the VR system because the majority of these top ten conditions are responsive to health promotion interventions. Individuals in the CIL sample, on the other hand, reported a greater number of secondary conditions, on average, than that VR sample.

Table 2: Secondary Conditions  Text Description of Table 2

Top Ten Secondary Conditions VR Average Severity Rating CIL Average Severity Rating
 Fatigue 1.67 1.50
 Deconditioning 1.71 1.54
 Sleep Disturbance 1.67 1.21
 Joint Pain 1.64 1.32
 Chronic Pain 1.62 1.21
 Depression 1.28  .92
 Arthritis 1.32  .96
 Weight 1.24 1.13
 Anger   .91   .80
 Mobility  .96 1.22


Using t-test group comparisons, the VR and CIL respondents had similar scores on the Health Promoting Lifestyle Inventory scale at baseline. However, the VR sample reported less satisfaction with overall health (p = .02) and more days of limitation due to health issues. Table 3 compares the two samples on reported days of limitation. There were significant group differences at baseline in days of limitation due to physical health, pain, anxiety, and difficulty sleeping.

Table 3: Days of Limitation  Text Description of Table 3

During the past 30 days, for about how many days… VR CIL Sig.
…was your physical health not good? 12.0   9.83 .02
…did poor physical or mental health health keep you from doing your usual activities, such as self-care, work or recreation?  8.45   7.63 .35
…was your mental health not good?  9.61   8.49 .22
…did pain make it hard for you to do your usual activities, such as self-care, work or recreation? 13.66   9.36 .00
…have you felt sad, blue or depressed?   9.79   8.24 .08
…have you felt worried, tense or anxious? 12.97   9.90 .00
…have you felt that you did not get enough rest or sleep? 16.07 11.58 .00


Next Steps

Over the next two years, RTC: Rural will collect longitudinal data from the VR sample at 6-month intervals. Follow-up data collection includes questions about the participant’s progression through VR services, including employment, training, and educational outcomes. These data will be used to create a regression model to determine the probability of successful employment placement, based on presenting secondary conditions and lifestyle behaviors.

Findings that link secondary health conditions, health promoting lifestyle behaviors, and employment outcomes (i.e. lower rates of secondary conditions and higher rates of health promoting behaviors are associated with better employment outcomes), build a case for VR support of health promotion services. CIL consumers experienced significant decreases in the incidence and prevalence of secondary conditions, significant improvements in health promoting lifestyle behaviors, and significant
decreases in medical costs after participation in the eight-week Living Well with a Disability health promotion program (Ravesloot, Seekins, & White, 2005). If these types of health changes contribute to successful employment outcomes, it will make sense for VR to fund health promotion activities.

Next steps include modifications to, and pilot testing of, the Living Well with a Disability health promotion curriculum in a VR setting.


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

Harris Interactive, Inc. (2004). N.O.D./Harris 2004 survey of Americans with disabilities (Study No. 20835). New York: Author.

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., & White, G. (2005). Living Well with a Disability health promotion intervention: Improved health status for consumers and lower costs for health care policymakers. Rehabilitation Psychology, 50, 239-245.

For more information, contact:

Catherine Ipsen, M.A.
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)

This research was supported by grant H133B030501 from the National Institute on Disability and Rehabilitation Research. Opinions expressed are the author’s and are not necessarily those of the funding agency. This factsheet was prepared by Catherine Ipsen RTC: Rural 2005. It is also available in standard, Braille, large print, and text formats.