Psychosomatics 43:400-404, October 2002
© 2002 The Academy of Psychosomatic Medicine
Effect of Employment on Quality of Life and Psychological Functioning in Patients With HIV/AIDS
Andrew C. Blalock, Ph.D.,
J. Stephen McDaniel, M.D., and
Eugene W. Farber, Ph.D.
Received Sept. 6, 2001; revision received March 19, 2002; accepted April 2, 2002. From the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine. Address reprint requests to Dr. Blalock, Emory University, Rollins School of Public Health, 3915 Cascade Rd., Suite 350, Atlanta, GA 30331; acblalo{at}sph.emory.edu (e-mail).
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ABSTRACT
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The need to address the role of employment in the psychosocial adjustment of persons with HIV/ AIDS has been consistently recognized in the clinical care and research literature. In this study, 200 volunteer HIV/AIDS patients completed questionnaires assessing medical and vocational histories, quality of life, and psychological functioning. Employed and unemployed participants did not significantly differ in terms of gender, education level, ethnicity, prevalence of diagnosed psychiatric and substance use disorders, or overall level of psychological functioning. However, with HIV illness severity statistically controlled, employed participants reported significantly higher overall quality of life.
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INTRODUCTION
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As people with HIV/AIDS adjust to living with a chronic illness, many new challenges emerge, among them issues of occupational functioning and employment.1 For working individuals, employment provides not only financial benefits but also may be a source of structure, social support, role identity, and meaning.2 Despite clinician recognition of the potential psychological significance of vocational issues, there has been little empirical investigation of employment status as it relates to HIV-related psychosocial adjustment. As such, the purpose of this study was to examine relationships between employment status and selected measures of psychosocial adjustment to HIV/ AIDS.
Adults with HIV infection and AIDS often struggle with vocational dilemmas. Unlike acute medical conditions in which patients may return to predisease levels of functioning after treatment, patients with HIV infection must frequently adapt to an unpredictable illness course.3–5 Even when physical health is stable, fear and uncertainty about how HIV disease will affect economic, occupational, and healthcare security complicate vocational decision making.6,7 While some leave the workforce and receive disability benefits, others remain employed to varying degrees. Those who do work often find their occupational functioning limited by HIV-specific factors such as episodic illness, fatigue, physical and cognitive limitations, medication schedules and side effects, and frequent medical appointments.2
Previous research has demonstrated that unemployed individuals generally report more depression, anxiety, social isolation, and low self-esteem than employed individuals.8–11 In the HIV/AIDS literature, studies that have incorporated employment as a variable of interest have yielded similar findings. For example, Lyketsos et al.12 found unemployment to be one of several variables that predicted higher rates of depression during disease progression, and Kelly et al.13 found that unemployment was one of several factors associated with suicidal ideation in HIV-seropositive patients. In a study of psychosocial vulnerability in HIV-seropositive gay men, Dickey et al.14 reported that younger men who lacked full-time employment were at greater risk for psychiatric symptoms and syndromal depression. Finally, Swindells et al.15 found that employment was one of several factors associated with improved quality of life.
Given that there are relatively few studies that focus specifically on the role of employment in psychosocial adjustment to HIV/AIDS, the primary objectives of this study were 1) to explore patterns of employment in a community-based group of individuals with symptomatic HIV disease and AIDS and 2) to examine the relationship between employment status, perceived quality of life, and psychological functioning. The investigators hypothesized that employed individuals would report better quality of life and higher psychological functioning than unemployed individuals.
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METHOD
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Participants and Setting
Two hundred adult HIV-seropositive volunteers were recruited for study participation at an urban public outpatient HIV/AIDS clinic. The clinic provides comprehensive medical services to primarily indigent patients who at some point during the course of their illness have had a CD4 count <200 cells/mm3. Patients were excluded from participation if they were receiving palliative care for severe or end-stage AIDS or if they had any significant physical, cognitive, or psychiatric condition that would interfere with protocol participation or compromise self-report reliability. Over 75% were receiving highly active antiretroviral therapy at the time of enrollment.
The median age of the participants was 40 years (range=22 to 63). Thirteen percent of the sample had less than 12 years of education, 39% had at least a high school or equivalent diploma, 34% reported some college education or specialized training, and 14% had completed an undergraduate or graduate degree. Seventy-five percent of the participants were male, and 25% were female. Regarding ethnicity, 70% were African American, 23% were Caucasian, 5% were Hispanic, and 2% were Asian American.
Assessment
We designed an employment and medical history questionnaire to obtain sociodemographic information, vocational history, HIV-related employment changes, and current employment/disability status. For the purpose of this study, employment was defined as any vocational activity for which the individual received declared ("on the books") or undeclared ("off the books") income on a part-time or full-time basis. Given that weekly work hours for individuals with HIV/AIDS may vary according to health status, part-time and full-time employment were defined as "on average" at least 10 hours per week and 30 hours per week, respectively. Information regarding year of HIV diagnosis and history of AIDS-related illnesses and hospitalizations was also included in the questionnaire. Medical record abstraction was used to obtain CD4 counts, viral load assay results, prescribed medication regimens, and any existing psychiatric diagnoses.
We used the 30-item version of the Medical Outcomes Study Health Status Questionnaire (MOS-30)16 to assess the impact of chronic illness on daily life. The MOS-30 has nine subscales: cognitive functioning, physical functioning, role functioning, social functioning, mental health functioning, pain, fatigue, perceived health distress, and health status transition. The mean score across all subscales yields a composite index score that was used as a general measure of quality of life in this study. The MOS-30 has been used validly and reliably as a quality of life measure for patients with HIV illness.16,17
The Brief Symptom Inventory18 yields scores on multidimensional scales of psychopathology. For the purposes of this study, we used the general severity index, which is derived across all scales of the Brief Symptom Inventory, as a single indicator of overall psychological functioning. The inventory has been reliably and validly used in psychiatric and medical studies, including large-scale studies involving patients with HIV/AIDS.19
To assess the presence of substance abuse and dependence disorders, we used the psychoactive substance use disorder module of the Structured Clinical Interview for DSM-IV, Non-Patient Version for HIV Studies (SCID-NP-HIV),20 which provides differential diagnoses according to DSM-IV criteria.
Procedures
Participants were recruited by research staff from clinic waiting rooms. After determining eligibility and obtaining informed consent, research staff gathered data during a 60-minute semistructured individual interview with each participant. All measures were conducted orally in counterbalanced order of administration. Participants who completed the assessment measures received $20 upon completion of the research protocol. Participants' medical records were reviewed to obtain HIV-related medical status/treatment information and psychiatric diagnosis.
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RESULTS
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Data analysis was conducted in two stages. The first stage involved descriptive information about the participants and patterns of employment; the second stage involved testing the primary hypotheses regarding differences between employed and unemployed groups on perceived quality of life and psychological functioning.
Patterns of Employment
Descriptive analysis revealed that of the 200 participants, 40% were employed, and 60% were unemployed. Among those employed, 38% were working full time, and 62% were working part time; 68% identified themselves as working exclusively "on the books," 28% exclusively "off the books," and 4% were receiving a combination of declared and undeclared income. Twenty-one percent reported that they had remained continuously employed throughout the course of their illness, and 31% reported that they had stopped working and had remained unemployed since diagnosis. However, 48% reported a fluctuating pattern of employment interrupted by periods of unemployment as a function of disease progression and medical status. Consistent with this finding, 66% of the unemployed group reported that they were considering returning to work or were actively seeking employment at the time of study enrollment. The average monthly reported income for the employed group was $1,936 compared with $608 for the unemployed group. Forty-five percent of those employed and 87% of those unemployed were also receiving disability benefits, indicating that employment status and disability status are not mutually exclusive.
Employment Status, Quality of Life, and Psychological Functioning
Prior to inferential hypothesis testing, preliminary analyses were conducted to evaluate relationships between employment status and specific demographic, mental health, and HIV-specific medical variables. A series of chi-square analyses revealed that there were no significant differences between the employed and unemployed groups in terms of education level ( 2=5.55, df=1, p<0.14) or ethnicity (2=0.001, df=1, p=0.999). Forty-three percent of the men in the study group were employed compared with 30% of the women; however, these proportions were not significantly different (2=3.20, df=1, p<0.08). The two groups also did not significantly differ in prevalence rates of psychiatric disorders as documented in the medical record (2=0.270, df=1, p<0.36) or psychoactive substance use disorders as assessed by the SCID-NP-HIV (2=0.405, df=1, p<0.18). However, analyses of variance examining HIV disease severity markers showed that the unemployed group was significantly more immunocompromised than the employed group, with a higher mean viral load (unemployed mean=66,864; employed mean=17,651) (F=6.66, df=1, 198, p<0.02) and a lower mean CD4 count (unemployed mean=299; employed mean=364) (F=4.34, df=1, 198, p<0.04).
The central research hypotheses were tested by using multivariate analysis of covariance. Since significant differences between the employment status groups were found for viral load and CD4, the degree of illness severity was statistically controlled by using those disease markers as covariates in the analysis. Raw scores on the Brief Symptom Inventory general severity index and the MOS-30 composite quality of life index were transformed to standardized T scores (mean=50, SD=10) before data analysis to facilitate comparison. This data transformation was for analysis purposes only, and the use of T scores does not infer any normative comparison to the general adult population. As shown in Table 1, multivariate tests were statistically significant for both the main effect of employment status and the covariance of viral load and CD4.
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TABLE 1. Effect of Employment Status and Degree of Illness Severity on Psychological Well-Being in 200 HIV/AIDS Patientsa
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Table 2 shows the results of the between-group analysis of quality of life and psychological functioning for the employment status groups. Controlling for disease severity, employed individuals reported a significantly higher level of perceived overall quality of life than did those who were unemployed; however, the two groups did not significantly differ in terms of their overall psychological functioning.
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DISCUSSION
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In this community-based group of individuals with HIV/ AIDS, 40% were employed, most of them on a part-time basis. While the majority were unemployed, over half of this group reported that they were considering returning to work or actively seeking employment, suggesting that employment is a salient concern for people with HIV/AIDS. Among the participants, employment histories since HIV diagnosis varied widely. Some people quit work entirely, whereas others were able to make adjustments to existing employment (e.g., reducing hours or taking on less physically/cognitively demanding tasks). However, the majority of participants described a post-HIV diagnosis work history characterized by periods of employment interspersed with periods of unemployment (e.g., personal leave, short-term medical leave, or quitting altogether until well enough to resume work).
Consistent with the first research hypothesis, employed participants reported significantly higher perceived quality of life than did unemployed participants. This result is consistent with the findings of Swindells et al.15 and suggests that employment may provide more than just financial benefits for persons with HIV/AIDS. Unlike the previous findings of Lyketsos et al.,12 Kelly et al.,13 and Dickey et al.,14 current data analysis did not support the second hypothesis that employed persons would also report better psychological functioning. Similarly, as noted in an exploratory follow-up analysis, there were no significant interaction effects between employment status and gender, ethnicity, or education level. However, these results are interpreted cautiously, since the relationship between psychological functioning and employment may be a complex one that was not fully captured by the study's methodology. First, the Brief Symptom Inventory is designed to measure symptomatic distress and does not capture dimensions of positive psychological functioning that may be important to consider in examining employment and psychological adjustment. Second, there is likely a meaningful difference between employment status (i.e., whether one works or not) and employment fit or satisfaction (i.e., the degree to which a particular job is matched with the individual's own limitations/symptom picture or how one subjectively feels about a particular job). Some individuals living with HIV/ AIDS may have a satisfactory job that does not tax their physical, cognitive, or emotional resources. Others may find that their employment situation actually adds to psychological stress levels or exacerbates existing disease-related problems.
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CONCLUSIONS
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Results of this investigation indicated that, for this outpatient clinical sample, employment status fluctuated over time as a function of changing medical status. By taking patients' unique symptom profiles and functional capacities into account, psychiatrists can play an important and valuable role in vocational adjustment decisions for their patients with HIV/AIDS. Results of the investigation also suggest that while employment is associated with improved overall quality of life, its relationship to psychological functioning is a complex phenomenon that requires further investigation. Future research in this area should examine broader dimensions of psychological adjustment, such as self-worth, autonomy, and affiliation. Longitudinally designed studies would also permit a more thorough and detailed exploration of the dynamic relationship between employment and psychosocial adjustment to HIV/AIDS over time.
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ACKNOWLEDGMENTS
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This study was supported by Emory Medical Care Foundation grant 99021. Dr. Blalock was supported by National Institute of Mental Health grant MH-20018. The authors thank Andrea Long, Lauren Pitkow, and Stacy Collins for their contribution to this project.
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REFERENCES
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J. G. Rabkin, M. McElhiney, S. J. Ferrando, W. Van Gorp, and S. H. Lin
Predictors of Employment of Men With HIV/AIDS: A Longitudinal Study
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January 1, 2004;
66(1):
72 - 78.
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ABSTRACT
INTRODUCTION
