vocational rehabilitation
Content
Epilepsy Research (2014) 108, 1469—1479
journal homepage: www.elsevier.com/locate/epilepsyres
Vocational rehabilitation service patterns
and employment outcomes of people with
epilepsy
Connie Sung a,∗, Veronica Muller b, Jana E. Jones c,
Fong Chan d
a
Michigan State University, United States
Hunter College, City University of New York, United States
c
University of Wisconsin School of Medicine & Public Health, United States
d
University of Wisconsin-Madison, United States
b
Received 1 February 2014; received in revised form 19 May 2014; accepted 13 June 2014
Available online 5 July 2014
KEYWORDS
Epilepsy;
Vocational
rehabilitation;
Employment
outcomes
Summary This study aimed to examine the association between vocational rehabilitation
(VR) services and employment outcomes of people with epilepsy (PWE), after controlling for
demographic covariates. Data was retrieved from the Rehabilitation Services Administration
Case Service Report (RSA-911) database for fiscal year (FY) 2011. Multivariate logistic regression was used to predict employment outcomes of PWE. Of the 2030 previously unemployed
PWE who received services, 884 (43.5%) achieved successful competitive employment. Results
indicate that higher education level and cost of VR services consumed were positively related
to successful employment. In contrast, having co-occurring anxiety/depression, receiving cash
benefits, or increasing time spent in the VR system was negatively associated with employment.
Eight specific VR services (e.g., education, vocational training, and job search and placement
assistance) were also found to be significant predictors of employment. Services provided by
state VR agencies were proven to be beneficial in improving employment outcomes. PWE should
be encouraged to pursue VR services to increase the chances of attaining employment. Health
care providers should also become familiar with the array of VR services.
Published by Elsevier B.V.
∗
Corresponding author at: Department of Counseling, Educational Psychology and Special Education, Michigan State University, 620 Farm
Lane, Room 460, East Lansing, MI 48824, United States.
Tel.: +1 517 353 1638; fax: +1 517 353 6393.
E-mail address: [email protected] (C. Sung).
http://dx.doi.org/10.1016/j.eplepsyres.2014.06.016
0920-1211/Published by Elsevier B.V.
1470
Introduction
Employment is fundamental for the physical health, psychological well-being, and quality of life of people with and
without disabilities, including people with epilepsy (PWE)
(De Boer, 2005; Dutta et al., 2008). As the fourth most
common neurological disorder, epilepsy affects nearly 2.2
million people in the United States, and more than 65 million people worldwide (Bishop and Chiu, 2011; Institute of
Medicine, 2012). While most PWE want to and are able to
work, employment is rather a ‘‘revolving door’’ for them,
due to seizure-related issues (Smeets et al., 2007). Despite
numerous employment-related services PWE can access,
their employment rate is considerably low and has not
changed substantially during the last three decades (Bishop
and Chiu, 2011; Smeets et al., 2007), and most experience difficulties in obtaining and maintaining competitive
employment (Bishop, 2004; Collings and Chappell, 1994).
With the unemployment rate of PWE at least two times
greater than that of the general population, as well as higher
than those with other disabilities (Carroll, 1992; Chaplin,
2005; Clarke et al., 2006; Theodore et al., 2006). PWE
are generally underemployed, and receive lower earnings
(Bishop and Chiu, 2011; Fisher and Schachter, 2000; Smeets
et al., 2007), which in turn can lead to depression, anxiety,
substance abuse, low self-esteem, and poor quality of life
(Dutta et al., 2008). In addition, the annual national costs
associated with epilepsy are estimated to be between $11.1
and $12.5 billion (Bishop et al., 2000; Engel and Pedley,
1997).
There is no single factor (e.g., seizure severity) that contributes to employment barriers faced by PWE (Clarke et al.,
2006; Smeets et al., 2007); rather they are the result of a set
of personal, functional, financial, psychosocial, and environmental factors and their complex interactions (Thorbecke
and Fraser, 1997). The literature indicates that the employment challenges for PWE, such as age, education, cognitive
impairment, and early onset of the disorder, though under
explored, have consistently been associated with lower
employment rates (Hauser and Hesdorffer, 1990; Yagi, 1998).
Other contributing factors include socioeconomic status
(Bautista and Wludyka, 2007), attitudes and beliefs of
employers (Bishop, 2002); job types and working conditions, workplace discrimination (Hawley et al., 2012), and
disability-related benefits. Despite the psychosocial benefits
of working, VR services that address many of these aspects
are not typically included in medical rehabilitation programs for people with chronic illness and disability (Hauser
and Hesdorffer, 1990). In addition, research on identifying
effective vocational interventions and service delivery models that facilitate work for PWE, increase job retention,
and promote employment outcomes have received relatively
less attention than those focused on identifying barriers
to employment. Nevertheless, a multidisciplinary approach,
vocational assessment, and rehabilitation have been identified as critical in helping to ease their work participation
(Tate et al., 2005).
The state-federal VR program has played a critical role
in helping PWD find and secure employment, and allocates more than US$2.5 billion dollars annually to fund VR
agencies across the states (U.S. Government Accountability
Office, 2005). It aims to provide services, ranging from
C. Sung et al.
assessment and diagnosis to job training and placement
(Parker and Patterson, 2012), to people whose impairments
or disabilities have hindered their ability to seek, obtain,
or retain competitive employment, and/or these services
(see Table 1). The VR program has been effective in achieving its primary objective, with the overall employment
rate for people with disabilities (PWD), after receiving VR
services, to be around 50—60% (Bolton et al., 2000). According to the Rehabilitation Services Administration’s (RSA)
Case Service Report (RSA-911) database, a total of 322,968
cases were closed as either successfully rehabilitated, with
55.5% placed in competitive employment, or unsuccessfully rehabilitated, with 45.5% not able to find competitive
employment after receiving VR services. Despite research
findings highlighting the potential benefits and need for VR
services, the employment level of PWE (43.5%) was lower
when compared to other developmental disability groups in
the fiscal year (FY) 2011. However, the associations between
each vocational intervention and the employment outcomes
of PWE are not well understood.
The purpose of this study was to examine the effect
of demographic variables and VR services on employment
outcomes for PWE who received services from the statefederal VR program using a large national dataset. Data
was retrieved from the U.S. Department of Education’s
RSA-911 database, which contains demographic data on all
individuals who receive services from state VR agencies in
the United States. A multifactorial approach to evaluate
how demographic variables and specific VR services affect
employment outcome can further hone existing interventions as well as develop new ones that are effective for
this population (Hauser and Hesdorffer, 1990; Mount et al.,
2005). The specific questions addressed were:
1. How do demographic variables and the provision of cash
or medical benefits affect the employment outcomes of
PWE after receiving VR services?
2. Which vocational rehabilitation services are directly
related to employment outcomes of PWE who received
services from state VR agencies?
Methods
Participants
Data were extracted from the archival database provided
annually to RSA by state VR agencies across the country.
The dataset (RSA-911 FY 2011 data) released by RSA at
the time of this study were used for the analyses. In FY
2011, there were data for 2030 previously unemployed PWE
whose cases were closed as either successfully rehabilitated, with 43.5% were placed in competitive employment,
or unsuccessfully rehabilitated, with 56.5% not able to find
competitive employment after receiving VR services. The
demographic characteristics and the case service information are presented in Table 2.
Study design and method
The dependent variable was competitive employment.
The RSA-911 manual defines competitive employment as
Description of services provided by state VR agencies.
Types of services
Descriptions of services
Assessment
Services provided and activities performed to determine an individual’s eligibility for VR services, to assign an individual to a priority
category of a state VR agency, and/or to determine the nature and scope of VR services to be included in the Individual Plan for
Employment (IPE).
Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and
supplies; this category includes diagnosis and treatment of mental and emotional disorders.
Therapeutic counseling and guidance services necessary to achieve an employment outcome, including personal adjustment
counseling; counseling that addresses medical, family, or social issues; vocational counseling; etc.
Full-time or part-time academic training above the high school level that leads to an associate/college/professional degree, a
certificate, or other recognized educational credential.
Occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical
school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or
certification.
Training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same
or a similar job upon successful completion.
Literacy training or training provided to remediate basic academic skills needed to function on the job in the competitive labor market.
Diagnosis and Treatment of
Impairments
Vocational Rehabilitation
Counseling and Guidance
College or University
Training
Occupational/Vocational
Training
On-the-Job Training
Basic Academic Remedial or
Literacy Training
Job Readiness Training
Augmentative Skills Training
Miscellaneous Training
Job Search Assistance
Job Placement Assistance
On-the-Job Supports
Transportation Services
Maintenance Services
Rehabilitation Technology
Reader Services
Vocational rehabilitation and employment outcomes
Table 1
Training to prepare an individual for the world of work (e.g., appropriate work behaviors and methods for being on time and increasing
productivity).
Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille,
speech reading, sign language, and cognitive training/retraining.
Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.
Job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes,
identifying appropriate job opportunities, and developing interview skills, and may include making contacts with companies on behalf
of the consumer.
A referral to a specific job resulting in an interview, whether or not the individual obtained the job.
Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job
retention; such services include job coaching, follow-up and follow-along, and job retention services.
Travel and related expenses necessary to enable an applicant or eligible individual to participate in a VR service; includes adequate
training in the use of public transportation vehicles and systems.
Monetary support provided for those expenses such as food, shelter and clothing that are in excess of the normal expenses of the
individual, and that are necessitated by the individual’s participation in the VR program.
The systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of individuals with
disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes
rehabilitation engineering services or assistive technology devices.
Services for individuals who cannot read print because of blindness or other disability (e.g., neurological disorders, specific learning
disabilities, or other impairments); includes reading aloud and transcribing printed information into Braille or sound recordings if
requested by the individual.
1471
Technical Assistance
Services
Information and Referral
Services
Other Services
Personal Attendant Services
Interpreter Services
Types of services
Table 1 (Continued)
Sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing,
and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language
interpretation.
Those personal services that an attendant performs for an individual with a disability such as bathing, feeding, dressing, providing
mobility and transportation, and so on.
Technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide
resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes.
Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the
VR program.
All other VR services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, initial stocks
and supplies, and medical care for acute conditions arising during rehabilitation and constituting a barrier to the achievement of an
employment outcome.
C. Sung et al.
Descriptions of services
1472
Table 2 Demographic characteristic for clients with
epilepsy (N = 2030).
Demographic variables
N (%)
Age
16—24
25—39
40—64
Gender
Men
Women
Race
European American
African American
Others (Hispanic, Asian, Native
American)
Education
Less than high school
High school graduate
Post-secondary
education/associate degree
Bachelor’s degree or above
Co-morbid psychiatric conditions
Yes
No
Co-morbid cognitive impairments
Yes
No
Cash benefits
Yes
No
Medical benefits
Yes
No
Employment status at closure
Employed (Status 26)
Not employed (Status 28)
884 (43.5%)
1146 (56.5%)
Case service variables
Mean (SD)
Age at application (year)
Time to become eligible (month)
Time in service (month)
Time until closure (month)
No. of services
Case expenditures (US$)
31.93 (12.70)
1.45 (1.85)
28.59 (26.30)
32.32 (27.29)
4.06 (2.23)
3815 (6267)
784 (38.6%)
615 (30.3%)
631 (31.1%)
1123 (55.3%)
907 (44.7%)
1252 (61.7%)
414 (20.4%)
364 (17.9%)
543 (26.7%)
820 (40.4%)
523 (25.8%)
144 (7.1%)
1751 (86.3%)
279 (13.7%)
1724 (84.9%)
306 (15.1%)
715 (35.2%)
1315 (64.8%)
815 (40.1%)
1215 (59.9%)
employment in an integrated setting, self-employment, or
employment in a state-managed Business Enterprise Program (BEP) that is performed on a full-time or part-time
basis, and compensated at or above the minimum wage.
Unsuccessful outcome refers to clients who were not working after completing their VR program.
Three sets of predictor variables were used: demographic
characteristics, work disincentives, and VR services. The
first set of predictor variables included gender, age at
application, race/ethnicity education level, co-occurring
psychiatric conditions and cognitive impairments, duration
and costs of services. The second set of predictor variables
included receipt of government, medical, or cash benefits.
Vocational rehabilitation and employment outcomes
1473
Table 3 Receipt of public support and medical insurance coverage of employed and unemployed clients with epilepsy at the
time of closure (N = 2030).
Support/insurance
SSI
TANF
GA
SSDI
VA
WC
OPA
CAID
CARE
PINSURE
EMPINS
OTHRINS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
All (N = 2030)
N (%)
Employed (N = 881)
N (%)
Unemployed (N = 1137)
N (%)
2 (df)
p
422 (21%)
1596 (79%)
58 (3%)
1956 (96%)
55 (3%)
1961 (97%)
369 (18%)
1645 (81%)
9 (0%)
2007 (99%)
8 (0%)
2008 (99%)
185 (9%)
1831 (90%)
662 (33%)
1358 (67%)
286 (14%)
1731 (85%)
52 (3%)
1965 (97%)
38 (2%)
1979 (97%)
515 (25%)
1503 (74%)
123 (6%)
758 (37%)
19 (1%)
862 (42%)
21 (1%)
860 (42%)
135 (7%)
746 (37%)
3 (0%)
878 (43%)
6 (0%)
875 (43%)
73 (4%)
808 (40%)
242 (12%)
638 (31%)
105 (5%)
774 (38%)
26 (1%)
854 (42%)
18 (1%)
862 (42%)
265 (13%)
615 (30%)
299 (15%)
838 (41%)
39 (2%)
1094 (54%)
34 (2%)
1101 (54%)
234 (12%)
899 (44%)
6 (0%)
1129 (56%)
2 (0%)
1133 (56%)
112 (6%)
1023 (50%)
420 (21%)
720 (35%)
181 (9%)
957 (47%)
26 (1%)
1111 (55%)
20 (1%)
1117 (55%)
250 (12%)
888 (44%)
45.67**
<0.001
2.93
0.087
0.70
0.403
9.41**
0.002
0.40
0.530
3.20
0.074
1.49
0.222
19.67**
<0.001
6.39*
0.011
0.88
0.348
0.22
0.639
17.32**
<0.001
Note: SSI, Supplemental Security Income; TANF, Temporary Assistance for Needy Families; GA, General Assistance; SSDI, Social Security Disability Insurance; VA, Veterans’ Disability Benefits; WC, Workers’ Compensation; OPA, Other Public Support; CAID, Medicaid;
CARE, Medicare; PINSURE, Public Insurance from Other Sources; EMPINS, Private Insurance Through Own Employment; OTHRINS, Private
Insurance Through Other Means.
* p < 0.05.
** p < 0.01.
The third set of predictor variables included each of the
types of VR services (see Table 1 for description).
Data analyses
Data were analyzed using SPSS 22.0. Hierarchical logistic
regression analysis was performed to examine the effect of
demographic covariates, work disincentives, and VR service
patterns on employment outcomes (employed/unemployed)
of PWE.
Results
Descriptive statistics
After receiving VR services, a total of 884 clients (43.5%)
were competitively employed. Refer to Table 2 for demographic characteristics and case service information. There
were no significant age or gender differences between the
employed and unemployed groups (p > 0.05). In terms of
race/ethnicity, the ratio of European American clients in
the employed group at closure was higher than that in
the unemployed group (2 (1, N = 2030) = 19.46, p < 0.001).
The clients in the successfully employed group were found
to have higher educational attainment than their counterparts in the unemployed group (2 (1, N = 2030) = 15.22,
p = 0.002). Significantly, more clients in the unemployed
group at closure received disability-related medical benefits (2 (1, N = 2030) = 29.93, p < 0.001) or cash benefits
(2 (1, N = 2030) = 53.93, p < 0.001), compared to those in
the employed group. Whilst, more clients in the unemployed group at closure had anxiety or depression than their
counterparts in the employed group (2 (1, N = 2030) = 5.78,
p = 0.016).
For the average time between submitting an application and becoming eligible for VR services, there was
no significant difference between both groups (p > 0.05).
However, the successfully employed group was found
to spend significantly less time in services (M = 26.09
months, SD = 25.73) than the unsuccessful group (M = 30.51
months, SD = 26.59; t(2028) = −3.77, p < 0.001). The successfully employed group also received significantly more
services (M = 4.61, SD = 2.15) than the unsuccessful group
(M = 3.64, SD = 2.20; t(2028) = 10.03, p < 0.001). Moreover,
average case expenditures for the successfully employed
group (M = $5013, SD = $6593) was higher than the unsuccessful group (M = $2890, SD = $5840; t(2028) = 7.68, p < 0.001).
1474
Table 4
C. Sung et al.
The use of vocational rehabilitation services (N = 2030).
Type of service
Use
condition
All
(N = 2030)
N (%)
Assessment
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1280 (63%)
750 (37%)
657 (32%)
1373 (68%)
1235 (61%)
795 (39%)
359 (18%)
1671 (82%)
265 (13%)
1765 (87%)
61 (3%)
1969 (97%)
30 (1%)
2000 (99%)
381 (19%)
1649 (81%)
20 (1%)
2010 (99%)
200 (10%)
1830 (90%)
570 (28%)
1460 (72%)
793 (39%)
1237 (61%)
342 (17%)
1688 (83%)
705 (35%)
1325 (65%)
331 (16%)
1699 (84%)
66 (3%)
1964 (97%)
2 (0%)
2028 (100%)
2 (0%)
2028 (100%)
4 (0%)
2026 (100%)
8 (0%)
2022 (100%)
365 (18%)
1665 (82%)
568 (28%)
1462 (72%)
Diagnosis and Treatment of Impairments
Vocational Rehabilitation Counseling and
Guidance
College or University Training
Occupational/Vocational Training
On-the-Job Training
Basic Academic Remedial or Literacy
Training
Job Readiness Training
Augmentative Skills Training
Miscellaneous Training
Job Search Assistance
Job Placement Assistance
On-the-Job Supports
Transportation Services
Maintenance Services
Rehabilitation Technology
Reader Services
Interpreter services
Personal attendant services
Technical Assistance Services
Information and Referral Services
Other Services
*
**
Employed
(N = 881)
N (%)
563 (28%)
321 (16%)
274 (13%)
610 (30%)
550 (27%)
334 (16%)
187 (9%)
697 (34%)
143 (7%)
741 (37%)
40 (2%)
844 (42%)
15 (1%)
869 (43%)
181 (9%)
703 (35%)
9 (0%)
875 (43%)
88 (4%)
796 (39%)
313 (15%)
571 (28%)
465 (23%)
419 (21%)
224 (11%)
660 (33%)
333 (16%)
551 (27%)
190 (9%)
694 (34%)
24 (1%)
860 (42%)
0 (0%)
884 (44%)
2 (0%)
882 (43%)
1 (0%)
883 (43%)
3 (0%)
881 (43%)
178 (9%)
706 (35%)
295 (15%)
589 (29%)
Unemployed
(N = 1137)
N (%)
717 (35%)
429 (21%)
383 (19%)
763 (38%)
685 (34%)
461 (23%)
172 (8%)
974 (48%)
122 (6%)
1024 (50%)
21 (1%)
1125 (55%)
15 (1%)
1131 (56%)
200 (10%)
946 (47%)
11 (1%)
1135 (56%)
112 (6%)
1034 (51%)
257 (13%)
889 (44%)
328 (16%)
818 (40%)
118 (6%)
1028 (51%)
372 (18%)
774 (38%)
141 (7%)
1005 (50%)
42 (2%)
1104 (54%)
2 (0%)
1144 (56%)
0 (0%)
1146 (56%)
3 (0%)
1143 (56%)
5 (0%)
1141 (56%)
187 (9%)
959 (47%)
873 (43%)
273 (13%)
2 (df)
p
0.27
0.603
1.34
0.247
1.25
0.263
12.95**
<0.001
13.45**
<0.001
12.41**
<0.001
0.52
0.473
2.99
0.084
0.02
0.895
0.02
0.892
41.64**
<0.001
120.56**
<0.001
80.61**
<0.001
5.97*
0.015
30.88**
<0.001
1.43
0.231
1.54
0.214
2.60
0.107
0.56
0.454
0.12
0.730
4.93*
0.026
22.58**
<0.001
p < 0.05.
p < 0.01.
In terms of the use of public support and medical insurance, SSI, SSDI, Medicaid, and Medicare were the top four
benefits received by state VR clients. Among the public support and medical insurance used by approximately
35—40% of the clients, there were significant relationships between the employment outcomes and SSI (2 (1,
N = 2030) = 45.67, p < 0.001), SSDI (2 (1, N = 2030) = 9.41,
p = 0.002), Medicaid (2 (1, N = 2030) = 19.67, p < 0.001), and
Medicare (2 (1, N = 2030) = 6.39, p = 0.011). More unemployed clients reported receiving these disability-related
benefits compared to employed clients at the time of closure
(see Table 3).
The most frequently received VR services were assessment (63.1%), followed by counseling and guidance (60.8%),
job placement assistance (39.1%), transportation (34.7%),
and diagnosis and treatment (32.4%). Among the services
Vocational rehabilitation and employment outcomes
received by over 5% of the clients, there were significant relationships between employment outcomes and
nine VR services: college or university training (2 (1,
N = 2030) = 12.95, p < 0.001), occupational or vocational
training (2 (1, N = 2030) = 13.45, p < 0.001), job search assistance (2 (1, N = 2030) = 41.64, p < 0.001), job placement
assistance (2 (1, N = 2030) = 120.56, p < 0.001), on-the-job
supports (2 (1, N = 2030) = 80.61, p < 0.001), transportation
services (2 (1, N = 2030) = 5.97, p = 0.015), maintenance services (2 (1, N = 2030) = 30.88, p < 0.001), information and
referral services (2 (1, N = 2030) = 4.93, p = 0.026), and other
services (2 (1, N = 2030) = 22.58, p < 0.001). The proportion
of each service provided to the employed group were higher
than those provided to the unemployed group (see Table 4).
Logistic regression analysis
The omnibus test for the overall logistic regression
model was found to be statistically significant, 2 (30,
N = 2030) = 506.99, p < 0.001. The Negelkerke R2 was computed to be 0.30, indicating a relatively robust effect size
(Cohen, 1988). The Hosmer and Lemeshow goodness of fit
test was insignificant, 2 (8, N = 2030) = 13.25 (p > 0.05), indicating that the model fits the data reasonably well. In the
first step, demographic covariates were entered. In this
step, race/ethnicity, education, co-occurring psychiatric
conditions, receipt of cash benefits, and duration and cost
of services, were found to be significant predictors. Specifically, PWE who are African Americans had a 34% reduction in
odds of obtaining employment (OR = 0.66; 95%CI: 0.51—0.85,
p = 0.001). Individuals who had at least a high school
degree or higher finding employment were 1.38—1.95
times greater than the odds of those with less than a
high school degree (high school degree: OR = 1.38; 95%CI:
1.07—1.77, p = 0.012; postsecondary education/associate
degree: OR = 1.72; 95%CI: 1.29—2.29, p < 0.001; college
degree: OR = 1.95; 95%CI: 1.27—3.00, p = 0.002). People who
received cash benefits had a 49% reduction in odds of obtaining employment (OR = 0.51; 95%CI: 0.40—0.66, p < 0.001)
compared to those who did not receive cash benefits.
Whilst, PWE with co-occurring anxiety/depression had a 31%
reduction in chances of finding employment in comparison to those without any co-occurring anxiety/depression
(OR = 0.69; 95%CI: 0.50—0.94, p = 0.017). Comparing to individuals who had less than or equal to $802 case expenditure,
those who consumed more cost of services had a 148%
(between $803 and $3498) to 488% (more than $3498)
increase in odds of obtaining employment (between $803
and $3498: OR = 1.48; 95%CI: 1.17—1.88; more than $3498:
OR = 4.88; 95%CI: 3.80—6.29). In contrast, when compared
to those who spent less than 400 days in the VR program,
people who spent longer time had a 51% (between 400
and 903 days) to 66% (more than 903 days) reduction in
odds of obtaining employment (between 400 and 903 days:
OR = 0.49; 95%CI: 0.39—0.62; more than 903 days: OR = 0.34;
95%CI: 0.26—0.44).
In the second step, 14 VR services were entered as predictors of the employment status at closure (with no receipt
of service as the reference category) while eight were not
entered as predictors because less than 5% of the clients
received those services. In this step, the odds ratios for
1475
race/ethnicity, education level and co-occurring psychiatric
conditions remained significant, with odds ratios computed
to be 0.68 (95%CI: 0.52—0.88, p = 0.004) for PWE who are
African Americans and 0.69 (95%CI: 0.50—0.94, p = 0.017)
for those who had co-occurring anxiety/depression. Comparing to PWE who had less than a high school degree,
those who have a high school degree, a post-secondary
education/associate degree, and a college degree, the
odds ratios were 1.30 (95%CI: 0.99—1.69, p = 0.050), 1.62
(95%CI: 1.19—2.20, p = 0.002), and 1.93 (95%CI: 1.23—3.02,
p = 0.004), respectively. The results suggested that African
American clients had significantly less chance of obtaining employment whereas clients who are more educated
had a greater chance of employment success. The odds
ratio for cash benefits was also significant and computed
to be 0.46 (95%CI: 0.35—0.60, p < 0.001), indicating that
clients receiving disability-related benefits (e.g., SSI, SSDI,
TANF) had a significantly less chance of finding employment. The odds ratio for costs of services more than $3498
was 2.94 (95%CI: 2.19—3.94, p < 0.001) whereas the odds
ratios for duration of services between 400—903 days and
more than 903 days were 0.46 (95%CI: 0.36—0.59, p < 0.001)
and 0.31 (95%CI: 0.23—0.42, p < 0.001), respectively. The
results indicated that clients having higher case expenditure and spending shorter duration in the VR program
had significantly more chance of obtaining employment.
After controlling for the effect of demographic covariates,
seven VR services were found to increase significantly the
chances of successful employment outcomes: (1) college or
university training (OR = 1.86; 95%CI: 1.37—2.52, p < 0.001);
(2) occupational or vocational training (OR = 1.54; 95%CI:
1.12—2.11, p = 0.008); (3) job search assistance (OR = 1.35;
95%CI: 1.04—1.76, p = 0.025); (4) job placement assistance
(OR = 2.62; 95%CI: 2.08—3.29, p < 0.001); (5) on-the-job
support (OR = 2.53; 95%CI: 1.88—3.41, p < 0.001); (6) maintenance services (OR = 1.85; 95%CI: 1.38—2.48, p < 0.001); and
(7) other services (OR = 1.35; 95%CI: 1.07—1.71, p < 0.001).
In contrast, diagnosis and treatment (OR = 0.72; 95%CI:
0.58—0.90, p = 0.003) was found to reduce the chances of
successful employment outcomes. The results are summarized in Table 5.
Discussion
This study further supports that services provided by
the state VR agencies play a critical role in assisting
PWD in their employment attainment process and significantly enhanced the employment outcomes of PWE
(Arango-Lasprilla et al., 2011; Bolton et al., 2000). College/university training, occupational/vocational training,
job search and job placement assistance, on-the-job support, maintenance services, and other services appeared
to be the most effective VR services. In addition, being
more educated, having no co-occurring anxiety/depression,
and not receiving cash benefits significantly increased the
chance of being successfully employed at closure. The
relation between higher education and higher chance of
employment success corresponded with other research
(Yagi, 1998). Furthermore, the results showed an effect of
race/ethnicity on employment—being an African American
reduces the chance of obtaining employment. In fact, this
1476
Table 5
C. Sung et al.
Hierarchical logistic regression analysis of vocational services and employment (N = 2030).
Step 1
ˇ
SE ˇ
Wald
df
p
OR
95%CI
Lower
Age
25—39
40—64
Gender
Female
Race
African American
Other Minority
Education
High school graduate
Post-secondary/associate
Bachelor’s degree or above
Co-existing psychiatric conditions
Co-existing cognitive disabilities
Cash benefits
Medical benefits
Cost of services
>$803 and <$3498
>$3499
Duration of services
>400 and <903 days
>904 days
Upper
−0.22
−0.29
0.13
0.14
2.80
4.52
1
1
0.094
0.034
0.80
0.75*
0.62
0.57
1.04
0.98
−0.06
0.10
0.36
1
0.548
0.94
0.78
1.14
−0.42
−0.17
0.13
0.13
10.43
1.65
1
1
0.001
0.199
0.66**
0.84
0.51
0.65
0.85
1.09
0.32
0.54
0.67
0.36
−0.01
−0.68
−0.12
0.13
0.15
0.22
0.15
0.14
0.13
0.12
6.28
13.52
9.20
5.80
0.01
27.45
1.02
1
1
1
1
1
1
1
0.012
<0.001
0.002
0.016
0.928
<0.001
0.311
1.38*
1.72**
1.95**
1.43*
0.99
0.51**
0.88
1.07
1.29
1.27
1.07
0.75
0.40
0.70
1.77
2.29
3.00
1.91
1.31
0.66
1.12
0.39
1.59
0.12
0.13
10.53
151.23
1
1
0.001
<0.001
1.48**
4.88**
1.17
3.79
1.88
6.29
−0.72
−1.08
0.12
0.13
35.69
66.48
1
1
<0.001
<0.001
0.49**
0.34**
0.39
0.26
0.62
0.44
ˇ
SE ˇ
2
p
OR
Step 2
df
95%CI
Lower
Age
25—39
40—64
Gender
Female
Race
African American
Other minority
Education
High school graduate
Post-secondary/associate
Bachelor’s degree or above
Co-existing psychiatric conditions
Co-existing cognitive disabilities
Cash benefits
Medical benefits
Cost of services
>$803 and <$3498
>$3499
Duration of services
>400 and <903 days
>904 days
Assessment
Diagnosis and treatment
Counseling and guidance
Upper
−0.18
−0.26
0.14
0.15
1.68
3.06
1
1
0.195
0.080
0.83
0.77
0.63
0.58
1.10
1.03
−0.06
0.11
0.33
1
0.564
0.94
0.77
1.16
−0.39
−0.08
0.14
0.14
8.17
0.33
1
1
0.004
0.563
0.68
0.92
0.52
0.69
0.88
1.22
0.26
0.48
0.66
0.38
−0.02
−0.78
−0.14
0.14
0.16
0.23
0.16
0.15
0.14
0.13
3.64
9.32
8.23
5.70
0.01
31.29
1.12
1
1
1
1
1
1
1
0.050
0.002
0.004
0.017
0.912
<0.001
0.291
1.30*
1.61**
1.93**
1.46*
0.98
0.46**
0.87
0.99
1.19
1.23
1.07
0.73
0.35
0.68
1.69
2.20
3.02
1.99
1.33
0.60
1.12
0.10
1.08
0.13
0.15
0.55
51.85
1
1
0.459
<0.001
1.10
2.94**
0.85
2.19
1.43
3.94
−0.77
−1.17
−0.19
−0.32
0.02
0.13
0.15
0.11
0.12
0.12
36.28
62.60
2.75
7.82
0.02
1
1
1
1
1
<0.001
<0.001
0.097
0.005
0.891
0.46**
0.31**
0.83
0.72**
1.02
0.36
0.23
0.66
0.58
0.81
0.59
0.42
1.03
0.91
1.28
Vocational rehabilitation and employment outcomes
Table 5
1477
(Continued ).
Step 2
ˇ
SE ˇ
2
df
p
OR
95%CI
Lower
College or university training
Occupational/vocational training
Job readiness training
Miscellaneous training
Job search assistance
Job placement assistance
On-the-job supports
Transportation services
Maintenance services
Information and referral
Other services
0.62
0.43
−0.05
−0.12
0.30
0.96
0.93
−0.19
0.62
0.22
0.30
0.16
0.16
0.14
0.18
0.13
0.12
0.15
0.12
0.15
0.14
0.12
15.85
7.14
0.14
0.47
5.04
66.67
37.84
2.57
17.17
2.33
6.23
1
1
1
1
1
1
1
1
1
1
1
<0.001
0.008
0.704
0.492
0.025
<0.001
<0.001
0.109
<0.001
0.127
0.013
1.86**
1.54**
0.95
0.88
1.35*
2.62**
2.53**
0.83
1.85**
1.25
1.35*
1.37
1.12
0.71
0.62
1.04
2.08
1.88
0.65
1.38
0.94
1.07
Upper
2.52
2.11
1.26
1.26
1.75
3.29
3.41
1.04
2.48
1.65
1.71
Note: OR, odds ratio. 95%CI, 95% confidence intervals. On-the-job training, basic academic remedial or literacy training, disabilityrelated, augmentative skills training, rehabilitation technology, reader services, interpreter services, personal attendant services, and
technical assistance services were not included as predictors because the number of clients receiving these services was minuscule (i.e.,
less than 5.0%).
* p < 0.05.
** p < 0.01.
is similar to previous studies, which have shown disparities in VR outcomes between Caucasian and minority clients
(Bautista and Wludyka, 2007).
This study found that receiving cash benefits is
negatively associated with employment outcome and constitutes a potential employment disincentive, which is
well-documented in VR outcome studies (Capella, 2002).
Arango-Lasprilla et al. (2011) indicated that legislative initiatives have attempted to curtail the disincentives of
disability benefit programs. However, awareness of these
work incentive initiatives does impact a recipient’s employment decisions. McMahon et al. (2000) also stated that
the possibility of returning to work is reduced drastically
when individuals with disabilities progress from using shortterm to long-term disability benefits and ultimately to SSDI.
Nevertheless, Hennessey (1997) found that if SSDI recipients had knowledge of the trial work period and the
extended period of benefits eligibility under new laws,
as well as assurance that they would continue receiving
Medicare/Medicaid benefits, the effect of work disincentives dissipated. Thus, VR professionals must ensure that
PWE understand the work incentives associated with federal
benefits and become familiar with benefits counseling and
financial planning/counseling services offered by the Social
Security Administration and state VR agencies.
Co-occurring mental health disorders among PWE are
frequent. The prevalence of anxiety disorders has been
reported to be 22.4%, and that of depression are 32.5%
(Ottman et al., 2011). In some secondary care and specialist settings, the prevalence of anxiety disorders has been
reported to exceed 50% (Jones et al., 2005). In the present
study, over 13% clients were identified with co-occurring
depression or anxiety. Employment outcome studies have
found significant correlations between co-occurring psychiatric conditions with the chances of employment
after receiving vocational interventions (Livingston, 1981).
Ingraham et al. (1992) found that counselors in state VR
agencies were ill-equipped to identify psychiatric problems in their clients. Therefore, efforts have to focus on
continuous evaluation, identification, and management of
secondary mental health conditions along with VR administrators possibly providing in-service training on psychiatric
assessment and treatment.
In addition, this study revealed that seven VR services
significantly increased the odds for successful employment, including job placement assistance, job search
assistance, and other services, which were followed by college/university training, on-the-job supports, maintenance
services, and occupational/vocational training. The results
indicated that the three most common VR services were
not related to epilepsy per se, which highlights the need
to consider job-related assistance services and environmental factors in the provision of services. These frequently
delivered services appear to reflect important employment
supports for VR clients with epilepsy through managing
clients’ work performance by accommodating work environment and demands, as well as managing employers’
expectations by educating them about the client’s current
work functioning. Previous research, such as Mount et al.
(2005), showed that successful employment outcome was
often predicted by receipt of job training and related services; demographic and personal financial status variables
did not necessarily predict employment outcome. Unfortunately, previous studies have frequently been based on
relatively small samples, self-report, or from a single VR
program (Mount et al., 2005).
The present study confirms that job-related training and
support services are essential to achieve an employment
outcome, and college/university training is of main consideration. PWE with college degrees are employed at a
1478
higher rate than those without one. This finding is not surprising since education level has frequently been found
to be associated with employment status (Rätsepp et al.,
2000). This study suggests that providing assistance, for
instance advancing opportunities for job interviews and
occupational/vocational training, may improve employability rates (McReynolds and Garske, 2002). For example, job
placement services require that rehabilitation professionals understand their clients’ work capability and potential
as well as matching their clients’ residual functioning with
the appropriate job positions; this serves as a significant
predictor of employment outcomes and is consistent with
additional VR studies (Bolton et al., 2000; Catalano et al.,
2006). This study’s results also shed light on the value of
maintenance services as well as other services (e.g., occupational licenses and medical care for acute conditions) in
increasing competitive employment for PWE.
In addition, previous studies underscore the need for
effective vocational training programs to obtain and maintain employment for PWE (Bishop, 2002, 2004; Carroll, 1992;
Chaplin, 2005; De Boer, 2005). Carroll (1992) and Fraser
et al. (1984) indicated that comprehensive and specialized
employment training programs designed specifically for PWE
generally achieve better results than generalized disability programs (Carroll, 1992; Fraser et al., 1984). Varekamp
et al. (2006) provided further evidence that VR rehabilitation programs which focus on establishing workplace
accommodations, providing work-related skills, increasing
clients’ capabilities in dealing with work-related problems,
and providing training aimed at job retention have been successful. Therefore, supportive workplace culture, positive
social work milieu, and proper workplace accommodations
are factors that are positively associated with effective
return to work (Bishop, 2002).
Although our findings are limited in that epilepsy-specific
variables were not available for analysis (e.g., seizure type,
severity, frequency, etc.), they suggest that the provision of
specific VR services is one of the most important factors to
consider when pursuing successful employment. Specifically,
PWE who present for services through state VR agencies
will benefit most from services that include training and
related job services. Nevertheless, the lack of specificity
regarding epilepsy-specific medical information warrants
further investigation.
Limitations
First, due to the way how case service information was
recorded at various stages in the rehabilitation process, it
is possible that human input errors may have accidentally
been entered which caused inaccurate data. That being
said, these errors are assumed to be random and therefore
should not result in systematic data bias. Second, predictor
variables were limited to individual characteristics, work
disincentives and VR services in relation to employment
outcomes. Additional potential factors (e.g., rehabilitation
professionals’ competency, clients’ employment history and
work motivation, and employer attitudes and behaviors)
that may affect employment outcomes were not included.
Third, the RSA-911 case service report does not collect data
on the seizure severity (e.g., specific types and frequency
C. Sung et al.
of seizure, number of antiepileptic drugs intake). It limits our ability to have a more in-depth understanding of
the relationships between seizure severity and successful
rate of VR services. Finally, this study used archival data
and employed an ex post facto design; therefore, causality
cannot be inferred.
Conclusion
Since PWE are at higher risk for unemployment or underemployment over time, vocational services provided by state
VR agencies represent a viable resource to assist them in
seeking and obtaining employment. Not only should this
population be encouraged to pursue VR services, but also
health care providers who are involved with their follow up
care should be familiar with these services and utilize them
as a viable option. Future studies investigating the specific
effects of certain vocational services for unemployed PWE
who qualify for these services are warranted.
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journal homepage: www.elsevier.com/locate/epilepsyres
Vocational rehabilitation service patterns
and employment outcomes of people with
epilepsy
Connie Sung a,∗, Veronica Muller b, Jana E. Jones c,
Fong Chan d
a
Michigan State University, United States
Hunter College, City University of New York, United States
c
University of Wisconsin School of Medicine & Public Health, United States
d
University of Wisconsin-Madison, United States
b
Received 1 February 2014; received in revised form 19 May 2014; accepted 13 June 2014
Available online 5 July 2014
KEYWORDS
Epilepsy;
Vocational
rehabilitation;
Employment
outcomes
Summary This study aimed to examine the association between vocational rehabilitation
(VR) services and employment outcomes of people with epilepsy (PWE), after controlling for
demographic covariates. Data was retrieved from the Rehabilitation Services Administration
Case Service Report (RSA-911) database for fiscal year (FY) 2011. Multivariate logistic regression was used to predict employment outcomes of PWE. Of the 2030 previously unemployed
PWE who received services, 884 (43.5%) achieved successful competitive employment. Results
indicate that higher education level and cost of VR services consumed were positively related
to successful employment. In contrast, having co-occurring anxiety/depression, receiving cash
benefits, or increasing time spent in the VR system was negatively associated with employment.
Eight specific VR services (e.g., education, vocational training, and job search and placement
assistance) were also found to be significant predictors of employment. Services provided by
state VR agencies were proven to be beneficial in improving employment outcomes. PWE should
be encouraged to pursue VR services to increase the chances of attaining employment. Health
care providers should also become familiar with the array of VR services.
Published by Elsevier B.V.
∗
Corresponding author at: Department of Counseling, Educational Psychology and Special Education, Michigan State University, 620 Farm
Lane, Room 460, East Lansing, MI 48824, United States.
Tel.: +1 517 353 1638; fax: +1 517 353 6393.
E-mail address: [email protected] (C. Sung).
http://dx.doi.org/10.1016/j.eplepsyres.2014.06.016
0920-1211/Published by Elsevier B.V.
1470
Introduction
Employment is fundamental for the physical health, psychological well-being, and quality of life of people with and
without disabilities, including people with epilepsy (PWE)
(De Boer, 2005; Dutta et al., 2008). As the fourth most
common neurological disorder, epilepsy affects nearly 2.2
million people in the United States, and more than 65 million people worldwide (Bishop and Chiu, 2011; Institute of
Medicine, 2012). While most PWE want to and are able to
work, employment is rather a ‘‘revolving door’’ for them,
due to seizure-related issues (Smeets et al., 2007). Despite
numerous employment-related services PWE can access,
their employment rate is considerably low and has not
changed substantially during the last three decades (Bishop
and Chiu, 2011; Smeets et al., 2007), and most experience difficulties in obtaining and maintaining competitive
employment (Bishop, 2004; Collings and Chappell, 1994).
With the unemployment rate of PWE at least two times
greater than that of the general population, as well as higher
than those with other disabilities (Carroll, 1992; Chaplin,
2005; Clarke et al., 2006; Theodore et al., 2006). PWE
are generally underemployed, and receive lower earnings
(Bishop and Chiu, 2011; Fisher and Schachter, 2000; Smeets
et al., 2007), which in turn can lead to depression, anxiety,
substance abuse, low self-esteem, and poor quality of life
(Dutta et al., 2008). In addition, the annual national costs
associated with epilepsy are estimated to be between $11.1
and $12.5 billion (Bishop et al., 2000; Engel and Pedley,
1997).
There is no single factor (e.g., seizure severity) that contributes to employment barriers faced by PWE (Clarke et al.,
2006; Smeets et al., 2007); rather they are the result of a set
of personal, functional, financial, psychosocial, and environmental factors and their complex interactions (Thorbecke
and Fraser, 1997). The literature indicates that the employment challenges for PWE, such as age, education, cognitive
impairment, and early onset of the disorder, though under
explored, have consistently been associated with lower
employment rates (Hauser and Hesdorffer, 1990; Yagi, 1998).
Other contributing factors include socioeconomic status
(Bautista and Wludyka, 2007), attitudes and beliefs of
employers (Bishop, 2002); job types and working conditions, workplace discrimination (Hawley et al., 2012), and
disability-related benefits. Despite the psychosocial benefits
of working, VR services that address many of these aspects
are not typically included in medical rehabilitation programs for people with chronic illness and disability (Hauser
and Hesdorffer, 1990). In addition, research on identifying
effective vocational interventions and service delivery models that facilitate work for PWE, increase job retention,
and promote employment outcomes have received relatively
less attention than those focused on identifying barriers
to employment. Nevertheless, a multidisciplinary approach,
vocational assessment, and rehabilitation have been identified as critical in helping to ease their work participation
(Tate et al., 2005).
The state-federal VR program has played a critical role
in helping PWD find and secure employment, and allocates more than US$2.5 billion dollars annually to fund VR
agencies across the states (U.S. Government Accountability
Office, 2005). It aims to provide services, ranging from
C. Sung et al.
assessment and diagnosis to job training and placement
(Parker and Patterson, 2012), to people whose impairments
or disabilities have hindered their ability to seek, obtain,
or retain competitive employment, and/or these services
(see Table 1). The VR program has been effective in achieving its primary objective, with the overall employment
rate for people with disabilities (PWD), after receiving VR
services, to be around 50—60% (Bolton et al., 2000). According to the Rehabilitation Services Administration’s (RSA)
Case Service Report (RSA-911) database, a total of 322,968
cases were closed as either successfully rehabilitated, with
55.5% placed in competitive employment, or unsuccessfully rehabilitated, with 45.5% not able to find competitive
employment after receiving VR services. Despite research
findings highlighting the potential benefits and need for VR
services, the employment level of PWE (43.5%) was lower
when compared to other developmental disability groups in
the fiscal year (FY) 2011. However, the associations between
each vocational intervention and the employment outcomes
of PWE are not well understood.
The purpose of this study was to examine the effect
of demographic variables and VR services on employment
outcomes for PWE who received services from the statefederal VR program using a large national dataset. Data
was retrieved from the U.S. Department of Education’s
RSA-911 database, which contains demographic data on all
individuals who receive services from state VR agencies in
the United States. A multifactorial approach to evaluate
how demographic variables and specific VR services affect
employment outcome can further hone existing interventions as well as develop new ones that are effective for
this population (Hauser and Hesdorffer, 1990; Mount et al.,
2005). The specific questions addressed were:
1. How do demographic variables and the provision of cash
or medical benefits affect the employment outcomes of
PWE after receiving VR services?
2. Which vocational rehabilitation services are directly
related to employment outcomes of PWE who received
services from state VR agencies?
Methods
Participants
Data were extracted from the archival database provided
annually to RSA by state VR agencies across the country.
The dataset (RSA-911 FY 2011 data) released by RSA at
the time of this study were used for the analyses. In FY
2011, there were data for 2030 previously unemployed PWE
whose cases were closed as either successfully rehabilitated, with 43.5% were placed in competitive employment,
or unsuccessfully rehabilitated, with 56.5% not able to find
competitive employment after receiving VR services. The
demographic characteristics and the case service information are presented in Table 2.
Study design and method
The dependent variable was competitive employment.
The RSA-911 manual defines competitive employment as
Description of services provided by state VR agencies.
Types of services
Descriptions of services
Assessment
Services provided and activities performed to determine an individual’s eligibility for VR services, to assign an individual to a priority
category of a state VR agency, and/or to determine the nature and scope of VR services to be included in the Individual Plan for
Employment (IPE).
Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and
supplies; this category includes diagnosis and treatment of mental and emotional disorders.
Therapeutic counseling and guidance services necessary to achieve an employment outcome, including personal adjustment
counseling; counseling that addresses medical, family, or social issues; vocational counseling; etc.
Full-time or part-time academic training above the high school level that leads to an associate/college/professional degree, a
certificate, or other recognized educational credential.
Occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical
school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or
certification.
Training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same
or a similar job upon successful completion.
Literacy training or training provided to remediate basic academic skills needed to function on the job in the competitive labor market.
Diagnosis and Treatment of
Impairments
Vocational Rehabilitation
Counseling and Guidance
College or University
Training
Occupational/Vocational
Training
On-the-Job Training
Basic Academic Remedial or
Literacy Training
Job Readiness Training
Augmentative Skills Training
Miscellaneous Training
Job Search Assistance
Job Placement Assistance
On-the-Job Supports
Transportation Services
Maintenance Services
Rehabilitation Technology
Reader Services
Vocational rehabilitation and employment outcomes
Table 1
Training to prepare an individual for the world of work (e.g., appropriate work behaviors and methods for being on time and increasing
productivity).
Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille,
speech reading, sign language, and cognitive training/retraining.
Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.
Job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes,
identifying appropriate job opportunities, and developing interview skills, and may include making contacts with companies on behalf
of the consumer.
A referral to a specific job resulting in an interview, whether or not the individual obtained the job.
Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job
retention; such services include job coaching, follow-up and follow-along, and job retention services.
Travel and related expenses necessary to enable an applicant or eligible individual to participate in a VR service; includes adequate
training in the use of public transportation vehicles and systems.
Monetary support provided for those expenses such as food, shelter and clothing that are in excess of the normal expenses of the
individual, and that are necessitated by the individual’s participation in the VR program.
The systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of individuals with
disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes
rehabilitation engineering services or assistive technology devices.
Services for individuals who cannot read print because of blindness or other disability (e.g., neurological disorders, specific learning
disabilities, or other impairments); includes reading aloud and transcribing printed information into Braille or sound recordings if
requested by the individual.
1471
Technical Assistance
Services
Information and Referral
Services
Other Services
Personal Attendant Services
Interpreter Services
Types of services
Table 1 (Continued)
Sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing,
and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language
interpretation.
Those personal services that an attendant performs for an individual with a disability such as bathing, feeding, dressing, providing
mobility and transportation, and so on.
Technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide
resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes.
Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the
VR program.
All other VR services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, initial stocks
and supplies, and medical care for acute conditions arising during rehabilitation and constituting a barrier to the achievement of an
employment outcome.
C. Sung et al.
Descriptions of services
1472
Table 2 Demographic characteristic for clients with
epilepsy (N = 2030).
Demographic variables
N (%)
Age
16—24
25—39
40—64
Gender
Men
Women
Race
European American
African American
Others (Hispanic, Asian, Native
American)
Education
Less than high school
High school graduate
Post-secondary
education/associate degree
Bachelor’s degree or above
Co-morbid psychiatric conditions
Yes
No
Co-morbid cognitive impairments
Yes
No
Cash benefits
Yes
No
Medical benefits
Yes
No
Employment status at closure
Employed (Status 26)
Not employed (Status 28)
884 (43.5%)
1146 (56.5%)
Case service variables
Mean (SD)
Age at application (year)
Time to become eligible (month)
Time in service (month)
Time until closure (month)
No. of services
Case expenditures (US$)
31.93 (12.70)
1.45 (1.85)
28.59 (26.30)
32.32 (27.29)
4.06 (2.23)
3815 (6267)
784 (38.6%)
615 (30.3%)
631 (31.1%)
1123 (55.3%)
907 (44.7%)
1252 (61.7%)
414 (20.4%)
364 (17.9%)
543 (26.7%)
820 (40.4%)
523 (25.8%)
144 (7.1%)
1751 (86.3%)
279 (13.7%)
1724 (84.9%)
306 (15.1%)
715 (35.2%)
1315 (64.8%)
815 (40.1%)
1215 (59.9%)
employment in an integrated setting, self-employment, or
employment in a state-managed Business Enterprise Program (BEP) that is performed on a full-time or part-time
basis, and compensated at or above the minimum wage.
Unsuccessful outcome refers to clients who were not working after completing their VR program.
Three sets of predictor variables were used: demographic
characteristics, work disincentives, and VR services. The
first set of predictor variables included gender, age at
application, race/ethnicity education level, co-occurring
psychiatric conditions and cognitive impairments, duration
and costs of services. The second set of predictor variables
included receipt of government, medical, or cash benefits.
Vocational rehabilitation and employment outcomes
1473
Table 3 Receipt of public support and medical insurance coverage of employed and unemployed clients with epilepsy at the
time of closure (N = 2030).
Support/insurance
SSI
TANF
GA
SSDI
VA
WC
OPA
CAID
CARE
PINSURE
EMPINS
OTHRINS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
All (N = 2030)
N (%)
Employed (N = 881)
N (%)
Unemployed (N = 1137)
N (%)
2 (df)
p
422 (21%)
1596 (79%)
58 (3%)
1956 (96%)
55 (3%)
1961 (97%)
369 (18%)
1645 (81%)
9 (0%)
2007 (99%)
8 (0%)
2008 (99%)
185 (9%)
1831 (90%)
662 (33%)
1358 (67%)
286 (14%)
1731 (85%)
52 (3%)
1965 (97%)
38 (2%)
1979 (97%)
515 (25%)
1503 (74%)
123 (6%)
758 (37%)
19 (1%)
862 (42%)
21 (1%)
860 (42%)
135 (7%)
746 (37%)
3 (0%)
878 (43%)
6 (0%)
875 (43%)
73 (4%)
808 (40%)
242 (12%)
638 (31%)
105 (5%)
774 (38%)
26 (1%)
854 (42%)
18 (1%)
862 (42%)
265 (13%)
615 (30%)
299 (15%)
838 (41%)
39 (2%)
1094 (54%)
34 (2%)
1101 (54%)
234 (12%)
899 (44%)
6 (0%)
1129 (56%)
2 (0%)
1133 (56%)
112 (6%)
1023 (50%)
420 (21%)
720 (35%)
181 (9%)
957 (47%)
26 (1%)
1111 (55%)
20 (1%)
1117 (55%)
250 (12%)
888 (44%)
45.67**
<0.001
2.93
0.087
0.70
0.403
9.41**
0.002
0.40
0.530
3.20
0.074
1.49
0.222
19.67**
<0.001
6.39*
0.011
0.88
0.348
0.22
0.639
17.32**
<0.001
Note: SSI, Supplemental Security Income; TANF, Temporary Assistance for Needy Families; GA, General Assistance; SSDI, Social Security Disability Insurance; VA, Veterans’ Disability Benefits; WC, Workers’ Compensation; OPA, Other Public Support; CAID, Medicaid;
CARE, Medicare; PINSURE, Public Insurance from Other Sources; EMPINS, Private Insurance Through Own Employment; OTHRINS, Private
Insurance Through Other Means.
* p < 0.05.
** p < 0.01.
The third set of predictor variables included each of the
types of VR services (see Table 1 for description).
Data analyses
Data were analyzed using SPSS 22.0. Hierarchical logistic
regression analysis was performed to examine the effect of
demographic covariates, work disincentives, and VR service
patterns on employment outcomes (employed/unemployed)
of PWE.
Results
Descriptive statistics
After receiving VR services, a total of 884 clients (43.5%)
were competitively employed. Refer to Table 2 for demographic characteristics and case service information. There
were no significant age or gender differences between the
employed and unemployed groups (p > 0.05). In terms of
race/ethnicity, the ratio of European American clients in
the employed group at closure was higher than that in
the unemployed group (2 (1, N = 2030) = 19.46, p < 0.001).
The clients in the successfully employed group were found
to have higher educational attainment than their counterparts in the unemployed group (2 (1, N = 2030) = 15.22,
p = 0.002). Significantly, more clients in the unemployed
group at closure received disability-related medical benefits (2 (1, N = 2030) = 29.93, p < 0.001) or cash benefits
(2 (1, N = 2030) = 53.93, p < 0.001), compared to those in
the employed group. Whilst, more clients in the unemployed group at closure had anxiety or depression than their
counterparts in the employed group (2 (1, N = 2030) = 5.78,
p = 0.016).
For the average time between submitting an application and becoming eligible for VR services, there was
no significant difference between both groups (p > 0.05).
However, the successfully employed group was found
to spend significantly less time in services (M = 26.09
months, SD = 25.73) than the unsuccessful group (M = 30.51
months, SD = 26.59; t(2028) = −3.77, p < 0.001). The successfully employed group also received significantly more
services (M = 4.61, SD = 2.15) than the unsuccessful group
(M = 3.64, SD = 2.20; t(2028) = 10.03, p < 0.001). Moreover,
average case expenditures for the successfully employed
group (M = $5013, SD = $6593) was higher than the unsuccessful group (M = $2890, SD = $5840; t(2028) = 7.68, p < 0.001).
1474
Table 4
C. Sung et al.
The use of vocational rehabilitation services (N = 2030).
Type of service
Use
condition
All
(N = 2030)
N (%)
Assessment
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1280 (63%)
750 (37%)
657 (32%)
1373 (68%)
1235 (61%)
795 (39%)
359 (18%)
1671 (82%)
265 (13%)
1765 (87%)
61 (3%)
1969 (97%)
30 (1%)
2000 (99%)
381 (19%)
1649 (81%)
20 (1%)
2010 (99%)
200 (10%)
1830 (90%)
570 (28%)
1460 (72%)
793 (39%)
1237 (61%)
342 (17%)
1688 (83%)
705 (35%)
1325 (65%)
331 (16%)
1699 (84%)
66 (3%)
1964 (97%)
2 (0%)
2028 (100%)
2 (0%)
2028 (100%)
4 (0%)
2026 (100%)
8 (0%)
2022 (100%)
365 (18%)
1665 (82%)
568 (28%)
1462 (72%)
Diagnosis and Treatment of Impairments
Vocational Rehabilitation Counseling and
Guidance
College or University Training
Occupational/Vocational Training
On-the-Job Training
Basic Academic Remedial or Literacy
Training
Job Readiness Training
Augmentative Skills Training
Miscellaneous Training
Job Search Assistance
Job Placement Assistance
On-the-Job Supports
Transportation Services
Maintenance Services
Rehabilitation Technology
Reader Services
Interpreter services
Personal attendant services
Technical Assistance Services
Information and Referral Services
Other Services
*
**
Employed
(N = 881)
N (%)
563 (28%)
321 (16%)
274 (13%)
610 (30%)
550 (27%)
334 (16%)
187 (9%)
697 (34%)
143 (7%)
741 (37%)
40 (2%)
844 (42%)
15 (1%)
869 (43%)
181 (9%)
703 (35%)
9 (0%)
875 (43%)
88 (4%)
796 (39%)
313 (15%)
571 (28%)
465 (23%)
419 (21%)
224 (11%)
660 (33%)
333 (16%)
551 (27%)
190 (9%)
694 (34%)
24 (1%)
860 (42%)
0 (0%)
884 (44%)
2 (0%)
882 (43%)
1 (0%)
883 (43%)
3 (0%)
881 (43%)
178 (9%)
706 (35%)
295 (15%)
589 (29%)
Unemployed
(N = 1137)
N (%)
717 (35%)
429 (21%)
383 (19%)
763 (38%)
685 (34%)
461 (23%)
172 (8%)
974 (48%)
122 (6%)
1024 (50%)
21 (1%)
1125 (55%)
15 (1%)
1131 (56%)
200 (10%)
946 (47%)
11 (1%)
1135 (56%)
112 (6%)
1034 (51%)
257 (13%)
889 (44%)
328 (16%)
818 (40%)
118 (6%)
1028 (51%)
372 (18%)
774 (38%)
141 (7%)
1005 (50%)
42 (2%)
1104 (54%)
2 (0%)
1144 (56%)
0 (0%)
1146 (56%)
3 (0%)
1143 (56%)
5 (0%)
1141 (56%)
187 (9%)
959 (47%)
873 (43%)
273 (13%)
2 (df)
p
0.27
0.603
1.34
0.247
1.25
0.263
12.95**
<0.001
13.45**
<0.001
12.41**
<0.001
0.52
0.473
2.99
0.084
0.02
0.895
0.02
0.892
41.64**
<0.001
120.56**
<0.001
80.61**
<0.001
5.97*
0.015
30.88**
<0.001
1.43
0.231
1.54
0.214
2.60
0.107
0.56
0.454
0.12
0.730
4.93*
0.026
22.58**
<0.001
p < 0.05.
p < 0.01.
In terms of the use of public support and medical insurance, SSI, SSDI, Medicaid, and Medicare were the top four
benefits received by state VR clients. Among the public support and medical insurance used by approximately
35—40% of the clients, there were significant relationships between the employment outcomes and SSI (2 (1,
N = 2030) = 45.67, p < 0.001), SSDI (2 (1, N = 2030) = 9.41,
p = 0.002), Medicaid (2 (1, N = 2030) = 19.67, p < 0.001), and
Medicare (2 (1, N = 2030) = 6.39, p = 0.011). More unemployed clients reported receiving these disability-related
benefits compared to employed clients at the time of closure
(see Table 3).
The most frequently received VR services were assessment (63.1%), followed by counseling and guidance (60.8%),
job placement assistance (39.1%), transportation (34.7%),
and diagnosis and treatment (32.4%). Among the services
Vocational rehabilitation and employment outcomes
received by over 5% of the clients, there were significant relationships between employment outcomes and
nine VR services: college or university training (2 (1,
N = 2030) = 12.95, p < 0.001), occupational or vocational
training (2 (1, N = 2030) = 13.45, p < 0.001), job search assistance (2 (1, N = 2030) = 41.64, p < 0.001), job placement
assistance (2 (1, N = 2030) = 120.56, p < 0.001), on-the-job
supports (2 (1, N = 2030) = 80.61, p < 0.001), transportation
services (2 (1, N = 2030) = 5.97, p = 0.015), maintenance services (2 (1, N = 2030) = 30.88, p < 0.001), information and
referral services (2 (1, N = 2030) = 4.93, p = 0.026), and other
services (2 (1, N = 2030) = 22.58, p < 0.001). The proportion
of each service provided to the employed group were higher
than those provided to the unemployed group (see Table 4).
Logistic regression analysis
The omnibus test for the overall logistic regression
model was found to be statistically significant, 2 (30,
N = 2030) = 506.99, p < 0.001. The Negelkerke R2 was computed to be 0.30, indicating a relatively robust effect size
(Cohen, 1988). The Hosmer and Lemeshow goodness of fit
test was insignificant, 2 (8, N = 2030) = 13.25 (p > 0.05), indicating that the model fits the data reasonably well. In the
first step, demographic covariates were entered. In this
step, race/ethnicity, education, co-occurring psychiatric
conditions, receipt of cash benefits, and duration and cost
of services, were found to be significant predictors. Specifically, PWE who are African Americans had a 34% reduction in
odds of obtaining employment (OR = 0.66; 95%CI: 0.51—0.85,
p = 0.001). Individuals who had at least a high school
degree or higher finding employment were 1.38—1.95
times greater than the odds of those with less than a
high school degree (high school degree: OR = 1.38; 95%CI:
1.07—1.77, p = 0.012; postsecondary education/associate
degree: OR = 1.72; 95%CI: 1.29—2.29, p < 0.001; college
degree: OR = 1.95; 95%CI: 1.27—3.00, p = 0.002). People who
received cash benefits had a 49% reduction in odds of obtaining employment (OR = 0.51; 95%CI: 0.40—0.66, p < 0.001)
compared to those who did not receive cash benefits.
Whilst, PWE with co-occurring anxiety/depression had a 31%
reduction in chances of finding employment in comparison to those without any co-occurring anxiety/depression
(OR = 0.69; 95%CI: 0.50—0.94, p = 0.017). Comparing to individuals who had less than or equal to $802 case expenditure,
those who consumed more cost of services had a 148%
(between $803 and $3498) to 488% (more than $3498)
increase in odds of obtaining employment (between $803
and $3498: OR = 1.48; 95%CI: 1.17—1.88; more than $3498:
OR = 4.88; 95%CI: 3.80—6.29). In contrast, when compared
to those who spent less than 400 days in the VR program,
people who spent longer time had a 51% (between 400
and 903 days) to 66% (more than 903 days) reduction in
odds of obtaining employment (between 400 and 903 days:
OR = 0.49; 95%CI: 0.39—0.62; more than 903 days: OR = 0.34;
95%CI: 0.26—0.44).
In the second step, 14 VR services were entered as predictors of the employment status at closure (with no receipt
of service as the reference category) while eight were not
entered as predictors because less than 5% of the clients
received those services. In this step, the odds ratios for
1475
race/ethnicity, education level and co-occurring psychiatric
conditions remained significant, with odds ratios computed
to be 0.68 (95%CI: 0.52—0.88, p = 0.004) for PWE who are
African Americans and 0.69 (95%CI: 0.50—0.94, p = 0.017)
for those who had co-occurring anxiety/depression. Comparing to PWE who had less than a high school degree,
those who have a high school degree, a post-secondary
education/associate degree, and a college degree, the
odds ratios were 1.30 (95%CI: 0.99—1.69, p = 0.050), 1.62
(95%CI: 1.19—2.20, p = 0.002), and 1.93 (95%CI: 1.23—3.02,
p = 0.004), respectively. The results suggested that African
American clients had significantly less chance of obtaining employment whereas clients who are more educated
had a greater chance of employment success. The odds
ratio for cash benefits was also significant and computed
to be 0.46 (95%CI: 0.35—0.60, p < 0.001), indicating that
clients receiving disability-related benefits (e.g., SSI, SSDI,
TANF) had a significantly less chance of finding employment. The odds ratio for costs of services more than $3498
was 2.94 (95%CI: 2.19—3.94, p < 0.001) whereas the odds
ratios for duration of services between 400—903 days and
more than 903 days were 0.46 (95%CI: 0.36—0.59, p < 0.001)
and 0.31 (95%CI: 0.23—0.42, p < 0.001), respectively. The
results indicated that clients having higher case expenditure and spending shorter duration in the VR program
had significantly more chance of obtaining employment.
After controlling for the effect of demographic covariates,
seven VR services were found to increase significantly the
chances of successful employment outcomes: (1) college or
university training (OR = 1.86; 95%CI: 1.37—2.52, p < 0.001);
(2) occupational or vocational training (OR = 1.54; 95%CI:
1.12—2.11, p = 0.008); (3) job search assistance (OR = 1.35;
95%CI: 1.04—1.76, p = 0.025); (4) job placement assistance
(OR = 2.62; 95%CI: 2.08—3.29, p < 0.001); (5) on-the-job
support (OR = 2.53; 95%CI: 1.88—3.41, p < 0.001); (6) maintenance services (OR = 1.85; 95%CI: 1.38—2.48, p < 0.001); and
(7) other services (OR = 1.35; 95%CI: 1.07—1.71, p < 0.001).
In contrast, diagnosis and treatment (OR = 0.72; 95%CI:
0.58—0.90, p = 0.003) was found to reduce the chances of
successful employment outcomes. The results are summarized in Table 5.
Discussion
This study further supports that services provided by
the state VR agencies play a critical role in assisting
PWD in their employment attainment process and significantly enhanced the employment outcomes of PWE
(Arango-Lasprilla et al., 2011; Bolton et al., 2000). College/university training, occupational/vocational training,
job search and job placement assistance, on-the-job support, maintenance services, and other services appeared
to be the most effective VR services. In addition, being
more educated, having no co-occurring anxiety/depression,
and not receiving cash benefits significantly increased the
chance of being successfully employed at closure. The
relation between higher education and higher chance of
employment success corresponded with other research
(Yagi, 1998). Furthermore, the results showed an effect of
race/ethnicity on employment—being an African American
reduces the chance of obtaining employment. In fact, this
1476
Table 5
C. Sung et al.
Hierarchical logistic regression analysis of vocational services and employment (N = 2030).
Step 1
ˇ
SE ˇ
Wald
df
p
OR
95%CI
Lower
Age
25—39
40—64
Gender
Female
Race
African American
Other Minority
Education
High school graduate
Post-secondary/associate
Bachelor’s degree or above
Co-existing psychiatric conditions
Co-existing cognitive disabilities
Cash benefits
Medical benefits
Cost of services
>$803 and <$3498
>$3499
Duration of services
>400 and <903 days
>904 days
Upper
−0.22
−0.29
0.13
0.14
2.80
4.52
1
1
0.094
0.034
0.80
0.75*
0.62
0.57
1.04
0.98
−0.06
0.10
0.36
1
0.548
0.94
0.78
1.14
−0.42
−0.17
0.13
0.13
10.43
1.65
1
1
0.001
0.199
0.66**
0.84
0.51
0.65
0.85
1.09
0.32
0.54
0.67
0.36
−0.01
−0.68
−0.12
0.13
0.15
0.22
0.15
0.14
0.13
0.12
6.28
13.52
9.20
5.80
0.01
27.45
1.02
1
1
1
1
1
1
1
0.012
<0.001
0.002
0.016
0.928
<0.001
0.311
1.38*
1.72**
1.95**
1.43*
0.99
0.51**
0.88
1.07
1.29
1.27
1.07
0.75
0.40
0.70
1.77
2.29
3.00
1.91
1.31
0.66
1.12
0.39
1.59
0.12
0.13
10.53
151.23
1
1
0.001
<0.001
1.48**
4.88**
1.17
3.79
1.88
6.29
−0.72
−1.08
0.12
0.13
35.69
66.48
1
1
<0.001
<0.001
0.49**
0.34**
0.39
0.26
0.62
0.44
ˇ
SE ˇ
2
p
OR
Step 2
df
95%CI
Lower
Age
25—39
40—64
Gender
Female
Race
African American
Other minority
Education
High school graduate
Post-secondary/associate
Bachelor’s degree or above
Co-existing psychiatric conditions
Co-existing cognitive disabilities
Cash benefits
Medical benefits
Cost of services
>$803 and <$3498
>$3499
Duration of services
>400 and <903 days
>904 days
Assessment
Diagnosis and treatment
Counseling and guidance
Upper
−0.18
−0.26
0.14
0.15
1.68
3.06
1
1
0.195
0.080
0.83
0.77
0.63
0.58
1.10
1.03
−0.06
0.11
0.33
1
0.564
0.94
0.77
1.16
−0.39
−0.08
0.14
0.14
8.17
0.33
1
1
0.004
0.563
0.68
0.92
0.52
0.69
0.88
1.22
0.26
0.48
0.66
0.38
−0.02
−0.78
−0.14
0.14
0.16
0.23
0.16
0.15
0.14
0.13
3.64
9.32
8.23
5.70
0.01
31.29
1.12
1
1
1
1
1
1
1
0.050
0.002
0.004
0.017
0.912
<0.001
0.291
1.30*
1.61**
1.93**
1.46*
0.98
0.46**
0.87
0.99
1.19
1.23
1.07
0.73
0.35
0.68
1.69
2.20
3.02
1.99
1.33
0.60
1.12
0.10
1.08
0.13
0.15
0.55
51.85
1
1
0.459
<0.001
1.10
2.94**
0.85
2.19
1.43
3.94
−0.77
−1.17
−0.19
−0.32
0.02
0.13
0.15
0.11
0.12
0.12
36.28
62.60
2.75
7.82
0.02
1
1
1
1
1
<0.001
<0.001
0.097
0.005
0.891
0.46**
0.31**
0.83
0.72**
1.02
0.36
0.23
0.66
0.58
0.81
0.59
0.42
1.03
0.91
1.28
Vocational rehabilitation and employment outcomes
Table 5
1477
(Continued ).
Step 2
ˇ
SE ˇ
2
df
p
OR
95%CI
Lower
College or university training
Occupational/vocational training
Job readiness training
Miscellaneous training
Job search assistance
Job placement assistance
On-the-job supports
Transportation services
Maintenance services
Information and referral
Other services
0.62
0.43
−0.05
−0.12
0.30
0.96
0.93
−0.19
0.62
0.22
0.30
0.16
0.16
0.14
0.18
0.13
0.12
0.15
0.12
0.15
0.14
0.12
15.85
7.14
0.14
0.47
5.04
66.67
37.84
2.57
17.17
2.33
6.23
1
1
1
1
1
1
1
1
1
1
1
<0.001
0.008
0.704
0.492
0.025
<0.001
<0.001
0.109
<0.001
0.127
0.013
1.86**
1.54**
0.95
0.88
1.35*
2.62**
2.53**
0.83
1.85**
1.25
1.35*
1.37
1.12
0.71
0.62
1.04
2.08
1.88
0.65
1.38
0.94
1.07
Upper
2.52
2.11
1.26
1.26
1.75
3.29
3.41
1.04
2.48
1.65
1.71
Note: OR, odds ratio. 95%CI, 95% confidence intervals. On-the-job training, basic academic remedial or literacy training, disabilityrelated, augmentative skills training, rehabilitation technology, reader services, interpreter services, personal attendant services, and
technical assistance services were not included as predictors because the number of clients receiving these services was minuscule (i.e.,
less than 5.0%).
* p < 0.05.
** p < 0.01.
is similar to previous studies, which have shown disparities in VR outcomes between Caucasian and minority clients
(Bautista and Wludyka, 2007).
This study found that receiving cash benefits is
negatively associated with employment outcome and constitutes a potential employment disincentive, which is
well-documented in VR outcome studies (Capella, 2002).
Arango-Lasprilla et al. (2011) indicated that legislative initiatives have attempted to curtail the disincentives of
disability benefit programs. However, awareness of these
work incentive initiatives does impact a recipient’s employment decisions. McMahon et al. (2000) also stated that
the possibility of returning to work is reduced drastically
when individuals with disabilities progress from using shortterm to long-term disability benefits and ultimately to SSDI.
Nevertheless, Hennessey (1997) found that if SSDI recipients had knowledge of the trial work period and the
extended period of benefits eligibility under new laws,
as well as assurance that they would continue receiving
Medicare/Medicaid benefits, the effect of work disincentives dissipated. Thus, VR professionals must ensure that
PWE understand the work incentives associated with federal
benefits and become familiar with benefits counseling and
financial planning/counseling services offered by the Social
Security Administration and state VR agencies.
Co-occurring mental health disorders among PWE are
frequent. The prevalence of anxiety disorders has been
reported to be 22.4%, and that of depression are 32.5%
(Ottman et al., 2011). In some secondary care and specialist settings, the prevalence of anxiety disorders has been
reported to exceed 50% (Jones et al., 2005). In the present
study, over 13% clients were identified with co-occurring
depression or anxiety. Employment outcome studies have
found significant correlations between co-occurring psychiatric conditions with the chances of employment
after receiving vocational interventions (Livingston, 1981).
Ingraham et al. (1992) found that counselors in state VR
agencies were ill-equipped to identify psychiatric problems in their clients. Therefore, efforts have to focus on
continuous evaluation, identification, and management of
secondary mental health conditions along with VR administrators possibly providing in-service training on psychiatric
assessment and treatment.
In addition, this study revealed that seven VR services
significantly increased the odds for successful employment, including job placement assistance, job search
assistance, and other services, which were followed by college/university training, on-the-job supports, maintenance
services, and occupational/vocational training. The results
indicated that the three most common VR services were
not related to epilepsy per se, which highlights the need
to consider job-related assistance services and environmental factors in the provision of services. These frequently
delivered services appear to reflect important employment
supports for VR clients with epilepsy through managing
clients’ work performance by accommodating work environment and demands, as well as managing employers’
expectations by educating them about the client’s current
work functioning. Previous research, such as Mount et al.
(2005), showed that successful employment outcome was
often predicted by receipt of job training and related services; demographic and personal financial status variables
did not necessarily predict employment outcome. Unfortunately, previous studies have frequently been based on
relatively small samples, self-report, or from a single VR
program (Mount et al., 2005).
The present study confirms that job-related training and
support services are essential to achieve an employment
outcome, and college/university training is of main consideration. PWE with college degrees are employed at a
1478
higher rate than those without one. This finding is not surprising since education level has frequently been found
to be associated with employment status (Rätsepp et al.,
2000). This study suggests that providing assistance, for
instance advancing opportunities for job interviews and
occupational/vocational training, may improve employability rates (McReynolds and Garske, 2002). For example, job
placement services require that rehabilitation professionals understand their clients’ work capability and potential
as well as matching their clients’ residual functioning with
the appropriate job positions; this serves as a significant
predictor of employment outcomes and is consistent with
additional VR studies (Bolton et al., 2000; Catalano et al.,
2006). This study’s results also shed light on the value of
maintenance services as well as other services (e.g., occupational licenses and medical care for acute conditions) in
increasing competitive employment for PWE.
In addition, previous studies underscore the need for
effective vocational training programs to obtain and maintain employment for PWE (Bishop, 2002, 2004; Carroll, 1992;
Chaplin, 2005; De Boer, 2005). Carroll (1992) and Fraser
et al. (1984) indicated that comprehensive and specialized
employment training programs designed specifically for PWE
generally achieve better results than generalized disability programs (Carroll, 1992; Fraser et al., 1984). Varekamp
et al. (2006) provided further evidence that VR rehabilitation programs which focus on establishing workplace
accommodations, providing work-related skills, increasing
clients’ capabilities in dealing with work-related problems,
and providing training aimed at job retention have been successful. Therefore, supportive workplace culture, positive
social work milieu, and proper workplace accommodations
are factors that are positively associated with effective
return to work (Bishop, 2002).
Although our findings are limited in that epilepsy-specific
variables were not available for analysis (e.g., seizure type,
severity, frequency, etc.), they suggest that the provision of
specific VR services is one of the most important factors to
consider when pursuing successful employment. Specifically,
PWE who present for services through state VR agencies
will benefit most from services that include training and
related job services. Nevertheless, the lack of specificity
regarding epilepsy-specific medical information warrants
further investigation.
Limitations
First, due to the way how case service information was
recorded at various stages in the rehabilitation process, it
is possible that human input errors may have accidentally
been entered which caused inaccurate data. That being
said, these errors are assumed to be random and therefore
should not result in systematic data bias. Second, predictor
variables were limited to individual characteristics, work
disincentives and VR services in relation to employment
outcomes. Additional potential factors (e.g., rehabilitation
professionals’ competency, clients’ employment history and
work motivation, and employer attitudes and behaviors)
that may affect employment outcomes were not included.
Third, the RSA-911 case service report does not collect data
on the seizure severity (e.g., specific types and frequency
C. Sung et al.
of seizure, number of antiepileptic drugs intake). It limits our ability to have a more in-depth understanding of
the relationships between seizure severity and successful
rate of VR services. Finally, this study used archival data
and employed an ex post facto design; therefore, causality
cannot be inferred.
Conclusion
Since PWE are at higher risk for unemployment or underemployment over time, vocational services provided by state
VR agencies represent a viable resource to assist them in
seeking and obtaining employment. Not only should this
population be encouraged to pursue VR services, but also
health care providers who are involved with their follow up
care should be familiar with these services and utilize them
as a viable option. Future studies investigating the specific
effects of certain vocational services for unemployed PWE
who qualify for these services are warranted.
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