Job considerations among individuals with multiple sclerosis

Abstract

BACKGROUND:

Individuals with multiple sclerosis (MS) face multiple barriers to obtaining and maintaining employment. Therefore, we need to understand the job considerations deemed most important by persons with MS as they decide to obtain or maintain employment.

OBJECTIVE:

Identify: (1) the relative importance of 10 job considerations items from the Job Considerations Scale among participants with MS, and (2) the underlying factor structure of the items. The Job Considerations Scale was previously used with persons with spinal cord injury (SCI).

METHODS:

Self-reported employment outcomes were obtained from 1333 participants with MS identified through records of a clinical facility in the Southeastern United States specializing in MS treatment.

RESULTS:

The job considerations identified as most important were having insurance and benefits (4.21), enjoyment from work (4.06), and salary (4.00). Two factors emerged from the factor analysis - tangible and intangible considerations for working. Tangible factors relate to earnings, benefits, and advancement; whereas intangible factors relate more to social and personal aspects of employment.

CONCLUSIONS:

The tangible and intangible job considerations resulting from the factor analysis are consistent with similar research on SCI, establishing the validity and utility of the Job Considerations Scale with persons with MS.

Keywords

Multiple sclerosis job satisfaction work adjustment

1 Introduction

Multiple sclerosis (MS) is a chronic, often progressive, autoimmune disease of the central nervous system (CNS) that affects nerve tissue in the brain and along the spinal cord (Lassmann, 2011). More than 900,000 Americans are currently living with MS (NMSS, 2020), and nearly 2.5 million people worldwide are known to have the disease (Wallin et al., 2019). A diagnosis of MS can be conferred at any age, but initial symptoms most often manifest themselves during early adulthood, typically between the ages of 20 and 40 (Kalb, 2016). The ratio of women with MS has steadily increased, with current estimates suggesting MS is three times more common in women than men (Dunn & Steinman, 2013). Although historically seen most often in Whites in Western Europe and North America (DeLuca & Nocentini, 2011), MS occurs across racial/ethnic groups, and, in the United States (US), Black women may have a higher risk of developing MS than do White men or women (Langer-Gould et al., 2013).

The personal and environmental barriers experienced after MS can affect participation in multiple ways, including difficulties obtaining or maintaining employment. Employment rates in the MS community are some of the lowest among individuals with chronic disabilities (Sweetland et al., 2012), averaging around 40% in the US and internationally (Bishop et al., 2013; Julian et al., 2008; Schiavolin et al., 2013). A large portion of people with MS disengage from employment during the first 10 years after their diagnosis, with estimates ranging from 43% at three years post-diagnosis to 70% at year 10 (Multiple Sclerosis International Federation, 2016). This fact is especially troubling considering employment has consistently been associated with better physical and mental health and higher quality of life among adults with MS (Bishop et al., 2015; Chiu et al., 2015; Dorstyn et al., 2019).

Considerable research has focused on understanding the reasons for the high rate of unemployment among people with MS and exploring the predictors and correlates of employment status (Chiu et al., 2013; Roessler et al., 2015). The primary predictors of job loss following an MS diagnosis are the presence and severity of physical and cognitive symptoms, though demographic and environmental factors also play a role (Bishop & Rumrill, 2015; Nissen & Rumrill, 2016). It is important to note that several studies have suggested community characteristics, such as housing accessibility and affordability, access to transportation, and access to needed services and resources, have a significant impact on obtaining or maintaining employment after MS (Bishop et al., 2013; Chiu et al., 2013; Rumrill et al., 2015). More recently, substantial differences in employment rates have been related to differences in education level, as participants with a four year degree were found to have 1.95 greater odds of employment compared to those with no more than a high school certificate, and those with a postgraduate degree were 2.87 times more likely to be employed (Krause et al., 2019). This research has led to an improved understanding of the complexity of barriers to employment after MS and contributed to the development of more effective vocational rehabilitation interventions.

For all that is known about the factors associated with labor force participation among people with MS in general, very little is known about the specific considerations people with MS make in their decisions to stay at work or stop working following the onset of their illness. A qualitative study (Meade et al., 2016) of people with MS who participated in focus groups indicated the importance of work for people with MS cannot be measured by employment rate alone, as participants identified three categories of employment outcomes that meant the most to them: (1) Compensation, (2) Personal Well-being, and (3) Benefitting Others. The themes within these categories provided evidence that people with MS value work not only as a means of financial support but also as a social role, a way to stay active, and to retain one’s identity. These qualitative findings from MS (Meade et al., 2016) and from a second similar qualitative study (Meade et al., 2015) of persons with spinal cord injury (SCI) were used as the foundation for the development of a 10 item measure of job considerations among people with SCI (Krause et al., 2020). The resulting Job Considerations Scale measures two primary dimensions –tangible and intangible job considerations. The measure may be appropriate for people with MS as a brief screen of job considerations, but the factor structure has not been verified with people with MS.

1.1 Purpose

Our purpose is to identify the relative importance of 10 job considerations among participants with MS and identify the underlying factor structure. We have conducted both exploratory and confirmatory factor analysis. This study builds on the work with job considerations and SCI (Krause et al., 2020), using the same 10 items and being based upon distinct qualitative studies with MS (Meade et al., 2016) and SCI (Meade et al., 2015).

2 Methods

2.1 Participants

Institutional review board approval was obtained prior to initiating contact with participants who were enrolled from a specialty hospital in the Southeastern US. There were three preliminary eligibility criteria: (1) adult treated for MS, (2) at least one year had passed since diagnosis, and (3) under the traditional retirement age of 65 at diagnosis. There were initially 3291 individuals in the pool, 1333 of whom returned completed materials. There were 686 individuals who could not be contacted by phone and the remaining 1272 were non-respondents.

2.2 Procedures

Participants were sent a cover letter to describe the study and to alert them that materials would be forthcoming by mail, approximately 4–6 weeks prior to sending actual materials. Participants were also given the option of completing the measure online. A second mailing was sent to non-respondents, followed by a phone call, and a third mailing was done for those who had misplaced or discarded materials but were still interested in participating. Participants were offered $50 in remuneration for completing the materials.

2.3 Measures

As part of the research program, Quality Employment throughout the Work Lifecycle after Disability, two independent qualitative studies were conducted, one with MS and one with SCI. Although the current focus is MS, the SCI study is also relevant to the identification of the full content domain as both studies were conducted in tandem. Focus groups were held to discuss quality employment outcomes, including job considerations. Participants included 74 persons with MS and 44 persons with SCI. More detailed information on participants and procedures were previously reported (Meade et al., 2015, 2016). Focus group results revealed multiple and sometimes overlapping quality employment outcomes identified as important by those with MS and SCI who had worked since injury or diagnosis. A self-report measure of 10 items was developed based on the focus group results to measure important job considerations among people with physical disability. Each of the 10 items were presented with the following five response options: not important, somewhat important, moderately important, very important, and extremely important.

2.4 Analysis

The Statistical Package for the Social Sciences (SPSS, version 26.0) and the Analysis of Moment Structure graphics statistical software program (AMOS, version 26.0) were used for statistical analysis. Descriptive statistics were used to assess participant characteristics and importance level of each job considerations item. Exploratory factor analysis (EFA) was used to examine the factor structure of the Job Considerations Scale (Clark & Watson, 1995; Costello & Osborne, 2005; Floyd & Widaman, 1995). Confirmatory factor analysis (CFA) was used to confirm the measurement structure of the Job Considerations Scale obtained from EFA. The participant cohort was randomly split between the EFA and CFA. The 10 x 10 correlation matrix was subjected to principal axis factoring. Kaiser–Guttman’s “eigenvalues greater than one” rule was used to determine the number of factors to be extracted. In addition, Cattell’s scree test provided additional information (Cattell, 1966; Gorsuch, 1983). Both methods indicate a two-factor solution. The two-factor solution was rotated using oblique transformation to enhance interpretation of the factors (Floyd & Widaman, 1995). Items with factor loadings greater than 0.40 in one factor and less than 0.30 in other factors were retained. For CFA, we used three indexes that are not sensitive to large sample sizes to evaluate the goodness of fit of the CFA model (Weston et al., 2008). These indexes include the comparative fit index (CFI; should be equal or greater than 0.95), the root mean square error of approximation (RMSEA; should be less than 0.08), and the standardized root mean square residual (SRMR; should be less than 0.08).

3 Results

3.1 Participant characteristics

Participants were, on average, 49.4 years of age at the time of the study, 37.0 years at the time of MS diagnosis, and were 12.4 years post-diagnosis. The majority of participants were women (77.6%) and non-Hispanic Whites (67.6%), with 27.8% non-Hispanic Blacks. Current employment was indicated by 51.5%. The portion of participants holding a bachelor’s degree or higher was 66.2%. Over half of the participants were married or part of an unmarried couple (63.1%).

3.2 Relative importance of job considerations

The relative importance of each job consideration was identified in two ways. Table 1 first summarizes the breakdown of responses across categories, highlighting those with the highest response percentages, and, second, provides the average score across all rankings. Based on the latter, having health insurance and other benefits was most important to the study participants, with enjoyment from working and compensation following closely behind.

Table 1
Endorsement of importance of job considerations items

Importance

(1) (2) (3) (4) (5)

Not Somewhat Moderately Very Extremely

% Mean (SD)

Compensation 2.3 4.4 19.2 39.3 34.8 4.00 (0.96)

Health insurance and other fringe benefits 5.2 3.3 10.2 28.4 52.9 4.21 (1.09)

Opportunities for advancement 9.1 10.6 28.7 32.3 19.4 3.42 (1.18)

Recognition of performance 5.3 11.7 31.4 33.7 17.9 3.47 (1.08)

Social connections 6.0 14.4 33.5 32.9 13.2 3.33 (1.06)

Enjoyment from working 2.5 3.6 15.3 42.4 36.1 4.06 (0.94)

Opportunities for helping others 2.8 6.7 19.1 38.3 33.1 3.92 (1.02)

Feeling better about self from working 3.1 6.0 18.2 39.4 33.3 3.94 (1.01)

Staying busy 5.9 9.6 23.6 37.3 23.6 3.63 (1.12)

Others share the workload 12.7 19.4 31.8 24.1 12.0 3.03 (1.19)

	Importance
Compensation	2.3	4.4	19.2	39.3	34.8	4.00 (0.96)
Health insurance and other fringe benefits	5.2	3.3	10.2	28.4	52.9	4.21 (1.09)
Opportunities for advancement	9.1	10.6	28.7	32.3	19.4	3.42 (1.18)
Recognition of performance	5.3	11.7	31.4	33.7	17.9	3.47 (1.08)
Social connections	6.0	14.4	33.5	32.9	13.2	3.33 (1.06)
Enjoyment from working	2.5	3.6	15.3	42.4	36.1	4.06 (0.94)
Opportunities for helping others	2.8	6.7	19.1	38.3	33.1	3.92 (1.02)
Feeling better about self from working	3.1	6.0	18.2	39.4	33.3	3.94 (1.01)
Staying busy	5.9	9.6	23.6	37.3	23.6	3.63 (1.12)
Others share the workload	12.7	19.4	31.8	24.1	12.0	3.03 (1.19)

3.3 Exploratory factor analysis

Factorial structure of the 10-item Job Considerations Scale was evaluated using principal axis factoring analysis. Bartlett’s test of sphericity, which tests the overall significance of all the correlations within the 10×10 correlation matrix, was significant χ ² (45, N = 623) = 2304.91, p < 0.001, indicating that it was appropriate to use the factor analytic model on this set of data. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy indicated that the strength of the relationships among variables was good (KMO = 0.86, greater than 0.50), hence it was appropriate to proceed with the analysis (Gorsuch, 1983). Both the Kaiser-Guttman criterion (Kaiser & Rice, 1974) and Cattell’s scree test (Cattell, 1966) indicated a two-factor measurement structure, with 38.49% of the variance accounted for by the first factor and 9.73% for the second factor. The two-factor solution was rotated to simple structure using oblique rotation to enhance interpretation of the factors. An examination of the pattern matrix indicated there were six items in the first factor with loadings greater than 0.40 and less than 0.30 in the second factor. There were three items meeting the same criterion in the second factor. Item 4 (recognition of performance) had factor loadings less than 0.40 on both factors and was excluded from the CFA.

Based on a careful examination of the contents and themes of items associated with each factor, the first factor was labeled intangible job considerations and the second factor, tangible job considerations factor. Table 2 presents the means and standard deviations, factor loadings, communality (h²), eigenvalues, percentage of variance explained, and the internal consistency reliability coefficients (Cronbach’s alpha).

Table 2
Principal axis factoring results for the Job Considerations Scale

Items Mean (SD) Intangible Considerations Tangible Considerations h²

8. Feeling better about self from working 3.95 (0.99) 0.824 –0.084 0.620

7. Opportunities for helping others 3.92 (0.99) 0.775 –0.103 0.535

6. Enjoyment from working 4.05 (0.94) 0.716 0.051 0.550

9. Staying busy 3.62 (1.13) 0.683 –0.013 0.458

5. Social connections 3.29 (1.05) 0.607 0.063 0.409

10. Others share the workload 3.05 (1.20) 0.513 0.151 0.359

4. Recognition of performance 3.42 (1.09) 0.390 0.373 0.429

2. Health insurance and other fringe benefits 4.22 (1.07) –0.084 0.719 0.467

1. Compensation 4.03 (0.97) 0.001 0.694 0.483

3. Opportunities for advancement 3.38 (1.22) 0.152 0.631 0.512

M (SD) 3.69 (0.70) 3.65 (0.79) 5.10 (0.76)

Eigenvalue 3.85 0.97

% Variance 38.49% 9.73%

Cumulative % Variance 38.49% 48.22%

Cronbach’s alpha 0.84 0.73

Items	Mean (SD)	Intangible Considerations	Tangible Considerations	h²
8. Feeling better about self from working	3.95 (0.99)	0.824	–0.084	0.620
7. Opportunities for helping others	3.92 (0.99)	0.775	–0.103	0.535
6. Enjoyment from working	4.05 (0.94)	0.716	0.051	0.550
9. Staying busy	3.62 (1.13)	0.683	–0.013	0.458
5. Social connections	3.29 (1.05)	0.607	0.063	0.409
10. Others share the workload	3.05 (1.20)	0.513	0.151	0.359
4. Recognition of performance	3.42 (1.09)	0.390	0.373	0.429
2. Health insurance and other fringe benefits	4.22 (1.07)	–0.084	0.719	0.467
1. Compensation	4.03 (0.97)	0.001	0.694	0.483
3. Opportunities for advancement	3.38 (1.22)	0.152	0.631	0.512
M (SD)	3.69 (0.70)	3.65 (0.79)	5.10 (0.76)
Eigenvalue		3.85	0.97
% Variance		38.49%	9.73%
Cumulative % Variance		38.49%	48.22%
Cronbach’s alpha		0.84	0.73

3.3.1 Factor 1: Intangible job considerations

This factor comprises of six items with factor loadings ranging from 0.51 to 0.82. The central theme of this factor represents job considerations related to perceived psychosocial rewards of work (e.g., “Feeling better about self from working”). This factor accounts for 38.49% of the total variance. The Cronbach’s alpha was computed to be 0.84, indicating high reliability of the items constituting this factor. The mean rating for this factor was 3.65 (SD = 0.79).

3.3.2 Factor 2: Tangible job considerations

This factor is composed of three items with loadings ranging from 0.63 to 0.72. The central theme of this factor reflects job considerations related to the financial benefits of work (e.g., “Health insurance and other fringe benefits”). Three items loaded significantly onto this factor (ranging from 0.63 to 0.72). This factor accounts for 9.73% of the total variance. The Cronbach’s alpha was computed to be 0.73, indicating acceptable reliability of the items constituting this factor. The mean rating for this factor was 5.10 (SD = 0.76).

3.4 Confirmatory factor analysis

The two-factor measurement structure was cross-validated using CFA (Byrne, 2016). Determination of model-data fit were based on several fit indices. The CFA results indicate a marginal fit model: χ ² (26, N = 623) = 150.43, p < 0.001, CFI = 0.94, RMSEA = 0.09 (90% confidence interval [0.07, 0.10]), and the SRMR = 0.06 (less than 0.08). An examination of the modification indexes suggested that two pairs of error terms should be correlated to improve the model fit: (a) e8 (“Feeling better about self from working”) and e9 (“Staying busy”), and (b) e5 (“Social connections”) and e10 (“Others share the workload”). Correlated measurement errors can be the result of similar meaning or close to the meanings of words and phrases in the items (Harrington, 2009). The chi-square statistic for the re-specified two-factor model was still significant: χ ² (24, N = 623) = 106.47, p < 0.001. Alternative fit indexes not sensitive to sample size indicated a good fit for the two-factor model after correlating the two-pairs of error terms; CFI = 0.96 (greater than 0.95), RMSEA = 0.07 (less than 0.08; 90% confidence interval [0.06, 0.09]), and the SRMR = 0.05 (less than 0.08). In addition, all items in the two-factor model significantly loaded on their respective factors ranging from 0.63 to 0.73 for the tangible job considerations factor and 0.48 to 0.82 for the intangible job considerations factor (see Fig. 1).

Fig. 1

Two-factor model for the Job Considerations Scale.

4 Discussion

We identified the relative importance of 10 job considerations among those with MS and validated the factor structure of the Job Considerations Scale. Our findings with people with MS paralleled those from a cohort of participants with SCI using the same scale (Krause et al., 2020). This was anticipated, as the Job Considerations Scale was developed largely based on qualitative focus groups of people with SCI and MS (Meade et al., 2015, 2016). Endorsement of importance of the job considerations was similar across the two populations. In order, the top five job considerations endorsed by persons with MS were health insurance/fringe benefits, enjoyment from working, compensation, feeling better about self, and opportunities for helping others. For persons with SCI, the highest endorsement also was given to health insurance/fringe benefits, followed by enjoyment from working, feeling better about self, compensation, and staying busy.

Factor analysis with the MS sample mirrored that of the SCI study, resulting in two factors –intangible and tangible job considerations. Similar to the study with SCI, one item (recognition of performance) was split between the two factors for the MS sample, and, thus, was dropped from the analysis. Support for the intrinsic and extrinsic nature of the factors of the Job Considerations Scale can be found in self-determination theory (Ryan & Deci, 2000), which has been proposed as a theory of work motivation as it seeks to explain the internal and external motivators behind behavior (Gagne & Deci, 2005). Early advocates argued both intrinsic and extrinsic rewards are required in the workplace for total job satisfaction (Porter & Lawler, 1968). Our results suggest individuals with MS highly value tangible rewards from working but also want the intangible rewards of enjoyment from working and building self-worth.

4.1 Implications for vocational rehabilitation

The findings help rehabilitation professionals better understand the job considerations deemed most important by people with MS and how they are similar to other populations with disabilities, specifically SCI. The Job Considerations Scale provides a tool that can be used as a brief screening measure to help rehabilitation professionals understand individual differences as to which job considerations are most important to each individual. Jobs will differ in the extent to which they align with the individual’s job considerations, and this may be a valuable point of discussion in the vocational counseling setting. The measure is substantially shorter than more highly developed measures of job needs, such as the Minnesota Importance Questionnaire (Gay et al., 1971), consistent with serving as a brief and easy screening tool.

4.2 Study strengths and limitations

The primary strengths of the study are the use of qualitative groups in preliminary research to identify the content areas, applications of both EFA and CFA, and the ability to directly compare with research using another population – SCI (Krause et al., 2020). Notable limitations include the response rate, which was 51.2% of those who could be definitively contacted and 40.5% of the total pool. Further, the data were cross-sectional. Longitudinal analyses are needed to identify the relationship between job considerations and future outcomes. Lastly, identifying the pattern of importance placed on job considerations and identifying the factor structure are necessary steps, yet predictive analyses will be needed to ultimately evaluate the importance and utility of the instrument.

4.3 Future research

Additional research is needed to evaluate job considerations among individuals with other disabling conditions to determine whether the same pattern is observed. Specifically in terms of utilization of the Job Considerations Scale, more research is needed to identify how job considerations correspond with job satisfaction given the extent to which the job considerations are being met within the current job and the relationship of that correspondence with other indicators of employment outcomes.

5 Conclusion

The Job Considerations Scale may be used as a brief and easy screening tool to measure job considerations in a vocational rehabilitation setting. The identification of two underlying dimensions of job considerations –tangible and intangible –is consistent both with previous research with participants with SCI (Krause et al., 2020) and with self-determination theory as a theory of work motivation. The most important job consideration among people with MS was health insurance and fringe benefits, rather than compensation. More research is needed to evaluate the job considerations of persons in other diagnostic populations.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

his publication was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR; grant no. 90RT5035). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this publication do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government.

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	Importance
	(1)	(2)	(3)	(4)	(5)
	Not	Somewhat	Moderately	Very	Extremely
			%			Mean (SD)
Compensation	2.3	4.4	19.2	39.3	34.8	4.00 (0.96)
Health insurance and other fringe benefits	5.2	3.3	10.2	28.4	52.9	4.21 (1.09)
Opportunities for advancement	9.1	10.6	28.7	32.3	19.4	3.42 (1.18)
Recognition of performance	5.3	11.7	31.4	33.7	17.9	3.47 (1.08)
Social connections	6.0	14.4	33.5	32.9	13.2	3.33 (1.06)
Enjoyment from working	2.5	3.6	15.3	42.4	36.1	4.06 (0.94)
Opportunities for helping others	2.8	6.7	19.1	38.3	33.1	3.92 (1.02)
Feeling better about self from working	3.1	6.0	18.2	39.4	33.3	3.94 (1.01)
Staying busy	5.9	9.6	23.6	37.3	23.6	3.63 (1.12)
Others share the workload	12.7	19.4	31.8	24.1	12.0	3.03 (1.19)