Person-environment contextual factors as mediators for the relationship between symptom cluster and employment outcome in multiple sclerosis
by Kanako Iwanaga, Jia-Rung Wu, Xiangli Chen, Beatrice Lee, Antonio Reyes, Brian N. Phillips, Joseph Pfaller, and Fong Chan
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Person-environment contextual factors as mediators for the relationship between symptom cluster and employment outcome in multiple sclerosis.
Journal of Vocational Rehabilitation,
Multiple sclerosis (MS) symptoms often make it difficult for individuals with MS to stay at work or return to work. It is important to understand the relationship between symptom clusters and employment. Person-environment (P-E) contextual factors such as core self-evaluations (CSE) and social support have been found to be effective mediators for the relationship between disability and participation in rehabilitation research and may be able to reduce the adverse impact of MS symptom cluster on employment outcome of people with MS.
To evaluate the mediation effect of CSE and social support on the relationship between symptom cluster and employment in MS.
Quantitative descriptive research design using two simple mediation analyses. 154 persons with multiple sclerosis participated in this study.
Results show that symptom cluster, CSE, and social support were significantly related to employment. Both CSE and social support were significant mediators of the relationship between symptom cluster and employment, with CSE a stronger mediator than social support.
Managing MS symptoms and increasing CSE and social support will reduce the adverse impact of MS symptom cluster on employment outcome. Therefore, CSE and social support can be viewed as protective factors for maintaining employment in MS. These results provide support for the use of positive psychology interventions by vocational rehabilitation counselors working with individuals with multiple sclerosis.
Employment is considered to be an important public health intervention for people with multiple sclerosis (MS). Individuals with MS who are employed, whether full or part-time, have better psychosocial and health outcomes than individuals who are not employed (Chiu et al., 2015). Employment, even at low levels, is associated with better health and better overall functioning for people with disabilities (Chiu et al., 2015; Hall, Kurth, & Hunt, 2013; Muller et al., 2017). Studies have shown that individuals with disabilities who have unsteady employment or who are unemployed tend to experience more mental and physical health problems, consume higher amounts of alcohol, and report lower self-esteem and overall well-being when compared to employed adults (Dutta, Gervey, Chan, Chou, & Ditchman, 2008; Krause, Carter, Pickelsimer, & Wilson, 2008; Murali & Oyebode, 2004). Work is believed to be beneficial because it increases financial security and access to high-quality heath care, which in turn improves health status, social relationship, mental health, and quality of life (Jackson, Iezzi, & Lafreniere, 1996; Reisine, Fifield, Walsh, & Forrest, 2008).
According to the National Multiple Sclerosis Society (NMSS), approximately 400,000 individuals are living with MS in the United States (NMSS, 2014). MS is a chronic illness of the central nervous system that impacts physical, psychological, and social functioning (Tortorella et al., 2014; Tesar, Baumhackl, Kopp, & Gunther, 2003; Costa, Sa, & Calheiros, 2012). Age of onset for MS is generally between 20 and 50 years (McFadden et al., 2012). MS is associated with several symptoms that can result in loss of employment, economic and social status, and social relationships (Costa, Sa, & Calheiros, 2013; Pack, Szirony, Kushner, & Bellaw, 2014; Moore et al., 2013). MS symptoms have been studied in symptom clusters because they often co-occur and may have a compounding impact on an individual (Crayton & Rossman, 2006; Motl & McAuley, 2009; Motl, Suh, & Weikert, 2010). The study of symptoms clusters considers that multiple symptoms often occur concurrently and that co-occurring symptoms can provide a more useful construct for assessment and management than a single symptom (Dodd, Miaskowski, & Paul, 2001; Kim, McGuire, Tulman, & Barsevick, 2005; Miaskowski, Dodd, & Lee, 2004). Symptom clusters are defined as “three or more concurrent symptoms (e.g., pain, fatigue, sleep insufficiency) that are related to each other” (Dodd et al., 2001, p. 465). Symptoms associated with MS include pain, stress, depression, sleep problems, cognitive impairments and fatigue (Motl & McAuley, 2009).
Due to the progressive, unpredictable, and disabling nature of MS and its associated symptoms, employment rates for individuals with MS are low (O’Connor, Cano, Thompson, & Playford., 2005). Research shows that because of symptoms associated with MS and their impact on physical functioning, mental health, and social participation (Kwiatkowski et al., 2014; Ng, Amatya, & Khan, 2013), individuals with MS have lower community participation when compared to the general population (Khan & Pallant, 2007). Given the evidence of the benefits of work and considering that symptom clusters have a significant impact on participation for persons with MS, it is important that we better understand the relationship between symptom clusters and employment.
Rehabilitation researchers and scholars have long recognized the need to consider contextual and environmental factors in the development of effective practice (Chan, Taryvdas, Blalock, Strauser, & Atkins, 2009; Wright, 1983). Recent research on the World Health Organization’s (WHO) International Classification of Functioning (ICF) as a model for vocational rehabilitation (VR) demonstrates the importance of person-environment (P-E) contextual factors in mediating the effect of impairments on participation (Chan et al., 2009). The positive human traits factors of core self-evaluations (CSE) and social support are considered effective P-E contextual factors in ICF research (Smedema, Chan, & Phillips, 2014; Smedema, Chan, et al., 2015; Smedema, Pfaller, et al., 2015; Wilson et al., 2013).
Core self-evaluations (CSE) is a positive human trait construct that has received considerable attention as a positive person (P) variable in ICF research. It is defined as the overall, fundamental perception that people have about their worth and capability as human beings (Judge, Locke, Durham, & Kluger, 1998). The CSE construct was first developed as part of a theoretical framework to explain dispositional influences on job satisfaction (Judge, Locke, & Durham, 1997) and then extended to explain life satisfaction (Judge, Bono, Erez, & Locke, 2005). CSE is a higher order construct comprised of four lower-order traits: self-esteem, self-efficacy, locus of control, and emotional stability (Judge et al., 1998). Self-esteem is defined as a global appraisal of one’s self-worth (Rosenberg, 1965). Self-efficacy is defined as one’s belief in his or her ability to produce desired outcomes when performing specific activities and pursuing goals (Bandura, 1977). Emotional stability is defined as the tendency to feel calm and secure (Eysenck, 1990). The final CSE trait is locus of control, which is defined as one’s belief that he or she has personal control over events in life, rather than believing that events are controlled by others or fate (Rotter, 1966).
Judge et al. (2005) noted that individuals’ fundamental evaluations of themselves impact all their beliefs about their lives. Judge et al. (1998) notes that people who consider themselves to be good or competent will react differently to obstacles in life than individuals who believe they are incompetent. Correspondingly, people with MS who consider themselves to be competent and worthy might cope more adaptively to the symptoms associated with their condition and, believing themselves to be capable of working, put more effort into pursuing employment. Conversely, people with MS who feel they are incompetent or lacking value may succumb to their symptoms, concluding that any attempt they make at pursuing employment will result in failure. Therefore, individuals with high CSE may have higher levels of employment than those with low CSE. There have not been any studies of the relationship between CSE and employment for individuals with MS. However, Smedema, Chan, and Phillips (2014) performed a study analyzing the relationship between CSE and participation for individuals with spinal cord injury and found that CSE contributes to life satisfaction and participation, including work participation. The study also found that CSE has a unique role in increasing motivation to pursue goals, which also predicts participation and life satisfaction. Research has also shown that CSE contributes to life satisfaction for college students with disabilities because they are better able to cope with stress, maintain a positive mood, and build social supports (Smedema et al., 2015).
Social support is a positive environment (E) construct that performs a vital role in an individual’s health and well-being (Chronister, Johnson, & Berven, 2006; Chronister, Chou, Frain, & Cardoso, 2008; Wilson et al., 2013). Social support is defined as the social network in which an individual interacts, maintains contact, and shares with others (Costa et al., 2012). Social contacts are among the most important resources for promoting resilience in coping because they function as a buffer to mediate the impacts of stress (Martin & Martin, 2002). The benefits of strong social support for individuals with MS include reduced medical impairments, mortality, and increased quality of life, and community participation (Schwartz & Frohner, 2005; Yamout et al., 2013). Social support is also a facilitator to well-being and improved daily functioning for individuals with MS (Hamed, Tariah, & Hawamdeh, 2012). Although there is a paucity of studies regarding the relationship between social support and employment for individuals with MS, it is likely that having strong social support and the related benefits would increase the likelihood of employment for individuals with MS.
1.3Purpose of the study
To iterate, the positive effect of employment is well documented in the literature. However, the employment rate of people with MS is notoriously low. It is hypothesized that positive P-E factors could reduce the adverse effect of MS cluster symptom on employment. CSE and social support have been found to be effective P-E contextual factors for predicting community integration and participation in several disability groups (e.g., people with SCI and college students with disabilities). The purpose of the present study is to evaluate CSE and social support as P-E mediators for the relationship between symptom cluster and employment for persons with MS.
One hundred and fifty-four prime working-age adults with MS participated in the present study. Participants were recruited from two regional chapters of the National Multiple Sclerosis Society (NMSS) including the Greater Washington D.C./Maryland Chapter in Washington D.C. and the Wisconsin Chapter in Hartland, Wisconsin. Inclusion criteria required individuals to be (a) diagnosed with multiple sclerosis, (b) between the ages of 25 and 54 (prime working-age), and (c) currently living in the community. The mean age of the participants was 41.03 years (SD?=?8.04). Most of the participants were women (87%), married (53%), and white (83%). Participants in the current study were relatively well-educated with 88% having some college education, two- or four-year college degrees, or graduate degrees. Fifty-nine percent of the participants were employed either part-time or full-time. The average age of MS diagnosis was 32.28 years old (SD?=?8.56), with the majority of participants (86%) experiencing relapsing-remitting multiple sclerosis (RRMS). A detailed description of participant characteristics is presented in Table 1.
|Age of onset||32.28||8.56|
|Africa American||16 (10.4%)|
|Asian American/Pacific||3 (1.9%)|
|Native American||1 (0.6%)|
|Others||4 (2.5) %|
|Type of MS|
|A relapsing-remitting MS||133 (86.4%)|
|Secondary-progressive MS||16 (10.4%)|
|Primary-progressive MS||4 (2.6%)|
|Full-time employed||70 (45.5%)|
|Part-time employed||20 (13%)|
|Full-time homemaker||11 (7.1%)|
|Seeking employment||5 (3.2%)|
|Less than High School||2 (1.3%)|
|High school/GED||16 (10.4%)|
|Some college||45 (29.2%)|
|2-year College Degree||17 (11%)|
|4-year College Degree||48 (31.2%)|
|Master Degree||21 (13.6%)|
|Professional Degree||4 (2.6%)|
The Core Self-Evaluations Scale (CSES) developed by Judge, Erez, Bono, and Thoresen (2003) was used to assess CSE. The CSES is a 12-item measure (e.g., “I am confident I get the success I deserve in life”) and each item is rated on a 5-point Likert-type scale (1?=?strongly disagree to 5?=?strongly agree). CSE scores were calculated by summing the 12 CSES items, with higher scores indicating greater levels of CSE. The Cronbach’s alpha coefficient for CSES in the present study was computed to be 0.88.
Symptom cluster included separate measures of pain, stress, sleep difficulty, depression and fatigue. Pain was measured using a four-item version of the Numeric Pain Scale (NPS; Castarlenas, Jensen, von Baeyer, & Miro, 2017; Childs, Piva, & Fritz, 2005), which captures present levels of pain intensity (e.g., “How would you rate your pain right now?”) and past week pain (e.g., “How would you rate your worst level of pain during the last week?”). Each item is rated on a 11-point Likert-type scale, ranging from 0 (no pain) to 10 (worst imaginable pain). Pain scores are computed by averaging the four items, with higher scores indicating greater levels of pain. The Cronbach’s alpha coefficient for NPS in the present study was computed to be 0.94. Stress was measured by an abbreviated version of the Perceived Stress Questionnaire (PSQ; Levenstein et al., 1993). It is composed of 9 items (e.g., “During the past month, have you felt under pressure from deadlines?”) and each item is rated on a 4-point Likert type scale (1?=?almost never to 5?=?usually). Stress scores were calculated by averaging the nine items with higher scores indicating greater levels of stress. The Cronbach’s alpha coefficient for PSQ in the present study was computed to be 0.88.
Sleep difficulty was measured using an abbreviated version of the Medical Outcomes Study-Sleep Scale (MOS-Sleep; Stewart, & Ware, 1989). The MOS-Sleep Scale is comprised of four items (e.g., “How often during the past 4 weeks did you feel that your sleep was not quiet [moving restlessly, feeling tense, speaking, etc., while sleeping?”]), with each item rated on a 6-point Likert type scale (1?=?none of the time to 6?=?all of the time). Sleep difficulty scores were computed by averaging all four items, with higher scores indicating greater levels of sleep difficulty. The Cronbach’s alpha coefficient for MOS-Sleep in the present study was computed to be 0.63. Depression was measured using the Patient Health Questionnaire-4 (PHQ-4: Kroenke, Spitzer, Williams, & Lowe, 2009). The PHQ-4 is a 4-item measure (e.g., “Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?”), with each item is rated on a 4-point Likert type scale (0?=?not at all to 3?=?nearly everyday). Depression scores were calculated by summing the items, with higher scores indicating greater levels of depression. The Cronbach’s alpha coefficient for PHQ-4 in the present study was computed to be 0.90. Fatigue was measured using the abbreviated version of the Modified Fatigue Impact Scale (MFIS; Larson, 2013). The brief MFIS is a five-item measure (e.g., “Because of my fatigue during the past four weeks I have been less alert”), with each item rated on a 5-point Likert scale (0?=?never to 4?=?always). Fatigue scores were computed by averaging the MFIS items with higher scores indicating greater levels of fatigue. The Cronbach’s alpha coefficient for MFIS in the present study was computed to be 0.91. Exploratory factor analysis was computed for the symptom cluster variables with a one-factor solution and the participants’ factor scores were used to generate symptom cluster scores for the participants.
The Interpersonal Support Evaluation List (ISEL-12) developed by Cohen, Mermelstein, Kamarck, and Hoberman (1985) was used to assess perceived social support. The ISEL is a 12-item measure (e.g., “If I wanted to go on a trip for a day [for example, to the country or mountains], I would have a hard time finding someone to go with me.”), with items rated on a 4-point Likert scale (0?=?definitely false to 3?=?definitely true). Social support scores were computed by averaging the items with higher scores indicating greater levels of perceived social support. The Cronbach’s alpha coefficient for ISEL-12 in the present study was computed to be 0.86.
Participants were recruited by advertisements through monthly electronic newsletters and through a single round of direct email solicitation sent by NMSS chapters to their members. Participants who completed the online survey received a US$15 gift card upon completion of the study. The University of Wisconsin-Madison Institutional Review Board (IRB) approved this study.
The Statistical Package for the Social Sciences (SPSS) version 24.0 was used to compute descriptive statistics. The SPSS INDIRECT macro written by Preacher and Hayes (2008) was used to compute the mediation analysis.
Multiple sclerosis symptom cluster was found to be negatively associated with CSE (r?=?–0.70, p?r?=?–0.23, p?r?=?0.31, p?r?=?–0.26, p?r?=?–0.29, p?
Two simple mediation analyses were computed to evaluate the relationship between MS symptom cluster and employment status using CSE and social support as mediators.
The following are the equations for symptom cluster and employment with CSE as the mediator: