- What models of employment support programs and services are most effective and what are their key features?
Key take-home messages
- In the literature, employment support programs are typically referred to as “vocational rehabilitation programs” and include two primary approaches: supported employment programs and prevocational training programs.
- Prevocational training programs involve a period of preparation or training before clients are placed in temporary employment. After temporary employment clients are encouraged to transition to competitive employment.
- Supported employment programs encourage clients to get placed in competitive employment first and then receive intensive on-the-job support.
- The literature indicates that supported employment programs with a holistic approach (more specifically the Individual Placement and Support Program) are more effective than pre-vocational training programs.
- More research needs to be done on the vocational rehabilitation programs and the specific concerns of people living with HIV.
The issue and why it’s important
Since the introduction of antiretroviral therapy, HIV infection is now considered a chronic disease in the developed world. As a result, people living with HIV (PHAs) who once had to abandon the idea of working, now have a renewed opportunity to get back in the labour force if they can and wish to. Research has shown that there is a high prevalence of unemployment amongst PHAs.(4,8) In addition, PHAs with temporary employment were found to be 2.5 times more likely to be hospitalized or die compared with to those with stable employment.10 Many PHAs face multiple barriers to employment such as the uncertainty of disease progression, the potential loss of disability benefits, lack of employability (gaps in resume during periods of sickness), discrimination and stigmatization, disclosure concerns and workplace accommodation.(3,12) It is clear that there is a need for effective employment support programs to assist PHAs in overcoming these barriers and making the transition into the labour force.
What we found
We found six systematic reviews about the effectiveness of interventions targeted at persons with chronic diseases, such as severe mental illness, who were seeking to obtain or return to work. There were no review articles or systematic reviews about the effect of vocational rehabilitation programs specifically for PHAs. There are different approaches to developing and running employment support programs, which are typically referred to as “vocational rehabilitation programs”.(13) Under vocational rehabilitation the two main program theories are 1) pre-vocational training and 2) supported employment.11 Each of these approaches has their advantages and disadvantages.
Prevocational Training has been referred to in the literature as the “train-then-place”(13) approach. In this approach there is a period of preparation before clients enter into competitive employment.(2,8) It began in the 1950s as part of a strategy to help individuals with severe mental illness to return to work in New York city. (2,8) Participants in this program would come together in an organization called the Clubhouse where they would socialize, support each other and participate in a work ordered day. In the work ordered day, clients would work in crews, alongside staff, and contribute to the proper running of the Clubhouse. (2,8) The next step in the program was a period of Transitional Employment where the clients are placed in a series of temporary jobs which are controlled by the Clubhouse. The purpose of the transitional employment period is to help clients develop the skills and confidence required to cope with competitive employment. (2,8) Only once clients have achieved success in transitional employment are they encouraged to seek competitive employment. Alternatively, they may also return back to the work crews if they feel they are not ready for transitional employment. (2,8)
In the 1980s a new approach to vocational rehabilitation began, which has been referred to as the “place-then-train” approach.(13) This method was originally designed for people with learning disabilities.8 Instead of having a period of preparation, clients are immediately placed in competitive employment and provided with intensive-on-the-job support and training from personnel known as Job Coaches (1). (2,8) In the literature there is a variant of supported employment programs known as the Individual Placement and Support program (IPS).(8) This program has six key principles: 1) the goal is competitive employment in work settings integrated into a community‟s economy; 2) clients are expected to obtain jobs directly, rather than following lengthy pre-employment training (rapid job search); 3) rehabilitation is an integral component of mental health treatment rather than a separate service; 4) services are based on clients‟ preferences and choices; 5) assessment is continuous and based on real work experiences; and 6) follow-up support continues indefinitely.(8) In IPS programs, employment specialists work together with each client‟s treatment team, case manager and psychiatrist.(11) The specialist provides a full range of services such as identifying job interests, job finding and job support.(11)
Supported Employment vs Pre-vocational Training
Two of the six systematic reviews(7,8) we collected discussed the effectiveness of prevocational training versus supported employment programs, for persons with severe mental illness. In addition we also found two review articles(2,13),which discussed the effectiveness of pre-vocational training versus supported employment programs, for persons with severe mental illness. All four papers found evidence in favor of supported employment programs. In supported employment programs, individuals are more likely to obtain and keep competitive employment. It has been suggested that pre-vocational training is not as effective because it can promote dependency and deter clients from leaving the program to find and keep competitive employment without support services.(2,11) It has also been argued that pre-vocational training is not effective in teaching clients skills which can only be learning through experience (on the job).(11) Another advantage that has been found for supported employment programs is that they encourage clients to engage in career planning.(2) In pre-vocational training the goal is more about building work history through the period of transitional employment.(2)
Components of Employment Support Programs
There are many different types of vocational rehabilitation interventions in the literature and so there is inconclusive evidence about the effectiveness of specific program components or methods.(6) To start, there were two systematic reviews which looked at the effectiveness of employment support programs for persons with chronic diseases, mental illness and physical injuries.(6,14) Both of these reviews have suggested that programs, such as supported employment programs which sometimes use a holistic approach, may be more effective at helping people find jobs and stay in jobs. The International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization describes disability as an outcome of a process in which biological, psychological and social factors are interrelated.(14) From this perspective, disability is seen as a gap between personal capabilities and demands from the outside. Therefore, interventions aimed at persons with disabilities can reduce this gap by increasing capacity or reducing demand. These interventions can be aimed at the individual (e.g. behavior changes) or directed at external support (e.g. modifications to the physical and social environment).(14) This holistic approach to employment support programs necessitates the involvement of all the different stakeholders in the return to work process for persons with disabilities.(6,14) For example, this may include: the individual with the disability, the job coach, the workplace, the health professional and the case manager. Research has shown that programs which promote continuity of care and support services are beneficial and effective.(6)
A primary qualitative study with 25 PHAs from a vocational rehabilitation program called Multitasking Systems (MTS) were asked about their perception of the effectiveness of the program and found that the individualized approach to the program was essential.5 A systematic review on vocational interventions for the unemployed also confirmed that person-directed approaches to programming have been effective for persons with health conditions such as myocardial infarction, somatization, adjustment disorders, and non-specific low back pain.(1) Additionally, the participants in MTS indicated that they appreciated that the program included an incremental step-by-step process in which they were able the pace themselves. This was important because of the unpredictable nature of the course of HIV and the multifaceted concerns PHAs have during the return to work process. Participants had mixed concerns about the idea of transitional employment (as in the pre-vocational training approach) versus competitive employment (as in the supported employment approach). Some indicated that the temporary nature of transitional employment reduced the risk of failure and alleviated the pressure to perform when participants were uncertain of their health and work readiness.(5) However, some participants began to desire permanent competitive employment and viewed the end of temporary assignments as a rejection.(5) These perceptions indicate a need for employment specialists to assess their clients‟ work readiness and assign different interventions to each as necessary. Lastly, participants also noted the use of peers as program facilitators as a positive aspect. They indicated that they felt more comfortable with facilitators who not only shared their lived experience of HIV but also their experience of facing barriers and challenges to employment such as lack of education, lack of employment history, and lack of confidence.(5)
What we did
We searched the Cochrane Library for systematic reviews using the term employment. We then searched Medline for systematic reviews and primary literature using a combination of search terms: 1) (Employment, Supported OR Employment OR Rehabilitation, Vocational [all MeSH terms]) AND (HIV (text term) OR Chronic Disease [MeSH term]). The Medline search was limited to articles published since 2000 and used a search hedge to optimize the retrieval of systematic reviews.
Factors that may impact local applicability
The findings which have been summarized above were from reviews which were dealing primarily with persons with mental health conditions as well as some with chronic diseases and physical injuries. PHAs do have shared issues with the rest of the disability community, such as physical limitations, discrimination, concerns about time away from the work force and lack of confidence in job reentry capability5. However, PHAs also have some unique concerns which require sensitivity from employment support programs. For example, since the advent of anti-retroviral treatment, many PHAs who had previously abandoned the notion of going back to work, have now had to reverse their thinking. This transition from a „sick role‟ to a worker identity is one that may require specific counseling and support.5 Additionally, because of the stigma associated with HIV, PHAs may either prefer to access vocational services in a familiar setting such as an AIDS Service Organization or they may prefer the anonymity of receiving services in a general vocation rehabilitation setting.5 Special attention must also be paid to the structure of disability benefits in Canada and how this affects the process of returning to work for PHAs. In order to learn more about these types of issues, which are specific to PHAs, more research needs to be done about vocation rehabilitation for PHAs in Canada.
- Audhoe SS, Hoving JL, Sluiter JK, Frings-Dresen M. Vocational Inter-ventions for Unemployed: Effects on Work Participation and Mental Distress. A Systematic Review. Journal of Occupational Rehabilia-tion 2000;20:1-13.
- Bond GR, Drake RE, Mueser KT, Becker DR. An Update on Support-ed Employment for People with Severe Mental Illness. Psychiatric Services 1997;8(3):335-346.
- Brooks RA, Martin DJ, Ortiz DJ, et al. Perceived barriers to employ-ment among persons living with HIV/AIDS. AIDS Care 2004;16:756-766
- Burgoyne RW, Saunders DS. Quality of life among urban Canadian HIV/AIDS clinic outpatients. Internation-al Journal of STD and AIDS 2001; 12:505-512
- Conyers LM. The impact of voca-tional services and employment on people with HIV. Work 2004;205-214.
- Corbiere M, Shen J. A Systematic Review of Psychological Return to Work Interventions for People with Mental Health Problems and/or Physical Injuries. Canadian Journal of Community Mental Health 2006;25(2).
- Crowther RE, Marshall M, Bond GR, Huxley P. Helping people with se-vere mental illness to obtain work: systematic review. British Medical Journal 2001;322:204-208.
- Crowther R, Marshall M, Bond GR, Huxley P. Vocational Rehabiliation for People with Severe Mental Illness. Cochrane Database of Systematic Reviews 2010;11.
- Cunningham WE, Andersen RM, Katz MH, et al. The impact of com-peting subsistence needs and barriers on access to medical care for persons with human immunode-ficiency virus receiving care in the United States. Medical Care 1999; 37:1270-1281
- Dray-Spira R, Gueguen A, Persoz A, et al. Temporary employment, absence of stable partnership, and risk of hospitalization or death during the course of HIV infection. Journal of Acquired Immune Defi-ciency Syndrome 2005; 40:190-197
- Kinoshita Y, Furukawa TA, Omori IM, Watanabe N, Marshall M, Bond GR et al. Supported Employment for Adults with Severe Mental Ill-ness (Protocol for Review). Cochrane Database of Systematic Reviews 2010;11.
- Martin DJ, Brooks RA, Ortiz DJ, et al. Perceived employment barriers and their relation to workforce-entry intent among people with HIV/AIDS. Journal of Occupational Health Psychology 2003; 8:181-194
- Twamley EW, Jeste DV, Lehman AF. Vocational Rehabiliation in Schizo-phrenia and Other Psychotic Disor-ders: A Literature Review and Meta-Analysis of Randomized Control Trials. The Journal of Nervous and Mental Disease 2003;191:515-523.
- Varekamp I, Verbeek JH, van Dijk FJ. How can we help employers with chronic diseases to stay at work? A review of interventions aimed at job retention and based on an empowerment perspective. International Archives of Occupa-tional and Environmental Health 2006;80:87-97.
Rapid Response Service. Effectiveness and key features of employment support programs. Toronto, ON: Ontario HIV Treatment Network; February, 2012.
Alekhya Mascarenhas and Michael G. Wilson.