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The quality of life of single adults with severe disabilities participating in extended employment programs in Northern Israel.

The lack of consumers' perspective is central in understanding the quality of life of persons with severe disabilities participating in extended employment programs in Israel. According to the Israeli National Insurance Institute, persons with severe disability are defined as having at least 75% "medical disability", inability to support themselves from work or occupation, and not earning a sum equivalent to 25% of the average wage. Most of the persons with severe disabilities participating in extensive employment programs in Israel fit the above definition with inability to be placed in competitive employment and be gainfully employed.

Extended employment programs are defined as a work-oriented rehabilitation facility, operating in controlled environment for the provision of employment-related services. In Europe, legislators and policy makers use the term sheltered employment and it is viewed as a job-creation measure, established in order to create work for persons with severe disabilities who otherwise would not be likely to obtain work in the open employment market (Thornton & Lunt, 1997). About 3.4% of the workforce in the United States (US) is employed of same form of extended employment, a rate similar to that in Germany and France (Samony & Waterpalse, 1992).

Extensive employment programs known in the past as sheltered employment was discussed in the late 70's and 80's by several researchers as the core employment program for persons with severe disabilities that could not be competitively employed (Bellamy, Homer, & Inman, 1981; and; Brown, et al., 1984. Bellamy, Rhodes & Albin (1986) criticized the model as lacking continuum and movement toward competitive employment. Only 3-5% of all people in these settings actually moved toward competitive employment (Bellamy, Rhodes, & Albin, 1986). In addition, extended employment programs are based primarily on subcontract work, the kind of work available rarely resembles actual jobs in the community. A recent review of sheltered employment policies in 18 countries, including European countries and Australia, criticized these programs as providing inadequate working conditions and employment contracts (Thornton & Lunt, 1997).

Despite this significant criticism, extended employment programs are widely used by persons with severe disabilities (Mank, 1994). A review of the employment trends among persons with disabilities in the US between 1986-1992, revealed that parallel to the increased number of placements in competitive employment there was also a significant increase in participation in extended employment programs. Thornton and Lunt (1997) compared policies in 18 countries toward extended and sheltered employment programs and identified mixed attitudes. In some countries sheltered employment policies encouraged the expansion of programs and the creation of extended employment sector (France, Spain, and Portugal) and in others it was viewed as marginal (Australia and the UK).

While numerous studies have attempted to evaluate the effectiveness of these programs and the various training and production approaches that are utilized (Wehman, Kregel, Banks, Hill, & Moon, 1987), few studies have studied the consumers' perspective (Dudley & Struhsaker-Schatz, 1985; Goode, 1989) or their quality of life.

The current research examined the quality of life of Israeli single adults with severe disabilities participating in extended employment sites in Northern Israel as related to their personal characteristics, objective and subjective perception of their severity of disability and employment variables? The following literature review discusses variables associates with quality of life of participants in these programs.

Quality of life of persons with disabilities: A literature review

Quality of life has different conceptualizations ranging from "subjective well-being" to value-based approaches. Oleson (1990) defined quality of life as an individual's satisfaction or happiness with life in domains he or she considered important. Historically, the term was known as "life satisfaction" or "subjective well-being." It is often referred to as "overall quality of life" or "global quality of life" to distinguish it from "health related quality of life."

A person's assessment of the satisfaction with life involves two subjective considerations: how important a given domain is for that person, and how satisfied one is with that domain. Flanagan (1982) offered a useful taxonomy including five domains: Physical and material well being, relations with other people, social, community and civic activities, personal development, fulfillment and recreation.

Quality of life has become an important outcome measure in the disability area, especially related to persons with developmental disabilities. Schalock (1990) offered an interesting conceptualization of quality of life of persons with developmental disabilities. He reviewed three perspectives in assessing quality of life: social indicators, psychological indicators and goodness of fit. The social indicators generally refer to external, environmentally based conditions such as health, social welfare, friendships, standard of living, education, public safety, housing, neighborhood, and leisure. These indicators represent measures used to examine the collective quality of community life. The psychological indicators approach measures the subjective reactions to life experiences. It is assessed by variables such as psychological well-being, personal satisfaction or happiness.

Schalock and Keith (1993) offer a quality of life model for persons with developmental disabilities including concepts such as personal satisfaction, competence/productivity, empowerment/independence and social belonging/community integration. This integrative model reflects quality of life as related to the person's personal experience and objective circumstances, perception of reference others and personal beliefs. Schalock (1990, p. 1) strongly believes that quality of life refers to "a person's subjective experience of his or her life." Scherer (1988) identified two personal factors that are consonant with the term among persons with physical disabilities: the potential to improve life outcome and the perceived desire for assimilation into society.

The following is an attempt to review variables associated with quality of life of persons with disabilities in extended employment (sheltered employment) programs. Most of the studies reviewed participants with developmental disabilities in these programs.

The researchers identified groups of variables as predictors of quality of life: personal characteristics, severity of disability (objective and subjective measures) and those related to employment experience and outcome. In examining the association between personal data and quality of life, Stark and Falkner (1996) reported that young adults with developmental disabilities were more motivated to be involved in employment programs. The person's residential situation is associated to the person's quality of life. In this context, Griffin, Rosenberg, Cheyney and Greenberg. (1996) found that participants with intellectual disabilities in supported and sheltered employment programs in semi-independent residential programs reported greater self-esteem than those living at home with their families.

Two disability severity variables are associated with quality of life: Percentage of medical disability (an objective measure) and the person's perception his/her severity of disability (subjective measure). Kiernan, McGauhey and Scalock (1988) evaluated occupational measures of 113,000 persons with developmental disabilities in the US and found a relationship between severity of disability and job retention and wage. Persons with milder disability had higher retention rates and higher income compared to those with severe disabilities. Based on Israeli Social Security Administration data- base, Inbar (1998) found that only 32 percent of those with severe medical disability were employed after participating in vocational rehabilitation programs compared to 71 percent of persons with mild medical disability. Conversely, Fabian (1992) raised doubt about the validity of objective measures of disability in predicting rehabilitation outcome. She found that objective measurement of the degree of disability was a poor predictor of the person's perception of his/her well-being.

Based on the literature review, three employment variables relevant to person's quality of life in extended employment programs have been identified: years of seniority, monthly wage, and participation in non-employment activities. Whitehead (1986), who summarized the problems in sheltered employment programs n the US in the early 80's, focused on the low monthly wage received by most of the participants. Therefore, workers in these programs perceived themselves as inferior to those working in competitive settings.

Dudley and Struhsaker-Schatz (1985) studied the relationship between years of stay in sheltered employment workshop and employment outcome among persons with severe developmental disabilities. They reported that those working more years expressed greater satisfaction compared to newcomers who stayed there less than two years. The latter were dissatisfied about their employment status, work conditions and monthly wage. Fabian (1992) presented similar findings in studying workers with psychiatric disabilities participating in sheltered employment programs (Fabian, 1992). The researcher explained their dissatisfaction by their difficulty in stabilizing and adjusting to the new demands.

Contradicting findings were published recently by Crudden, McBroom, Skinner, & Moore (1998) regarding the association between length of stay in sheltered employment program and employment outcome among persons with visual impairment. The survey of 166 employed persons with visual impairments showed that level of satisfaction declined after five years of work in sheltered industries. Newcomers believed that they could move from there to competitive employment but those who worked longer felt that this goal was unrealistic.

Mosely (1988) interviewed persons with severe developmental disabilities who had moved from sheltered employment to supported employment settings and reported greater satisfaction due to higher monthly salaries they received in supported employment settings. Griffin et al. (1996) reported that persons with mild intellectual disabilities participating in sheltered employment programs expressed dissatisfaction about their work status and monthly wage.

Most of the sheltered employment settings also provide other benefits (Whitehead, 1986). These programs offer participants complimentary education, clinical services, and leisure and social activities. Do participants in sheltered employment programs tend to view the programs as employment or as providers of additional services such as leisure, friendship and social activities? According to Freedman and Fesko (1996) most of the participants with significant disabilities in their study perceived the sheltered employment program beyond work activities and as their main social milieu. Most of the service providers included social and leisure activities as part of or in addition to employment.

Based on the literature review we have examined the contribution of these variables on the quality of life of single workers in sheltered workshops.

Methodology

Population

The population studied included all of the 128 single persons with severe disabilities working in six extended employment facilities in the northern part of Israel. These facilities located in five cities and towns (Beit Shean, Hadera, Haifa (2), Nazareth, and Migdal Haemek) serve beneficiaries with severe disabilities. According to National Insurance Institute, those who are assigned to these programs cannot support themselves from work or occupation, and do not earn a sum equivalent to 25% of the average wage. Their personal (demographic) characteristics are presented in Table 1.

Participants' were persons with all types of severe disabilities, average age was in the early 30's, there were slightly more men than women. They had partial high school education, and the majority lived with their parents. In terms of the objective measure of severity of disability, the mean was 91.7% medical disability. Conversely, in subjective terms, the majority of the participants perceived the severity of their disability as mild to moderate. Participants in these programs had a mean of five years of seniority (stay), a monthly wage of slightly above 400 Shekels (the minimum monthly wage in Israel is slightly above 3,000 Shekels) in addition to their social security benefits.

Instrumentation

The questionnaire was consisted of four sections: (a) personal (demographic) data included the following information: gender, age, and living situation (living independently, in a semi-sheltered residence and with parents); (b) disability data included type of disability (physical, cognitive, psychiatric), severity of disability measured by percentage of medical disability as determined by the Medical Decision Committee of Social Security Administration (called in Israel the Social Insurance Institute) and the participant's subjective perception of the severity of his/her disability (mild, moderate, severe); (c) employment data included the following: years of seniority (stay) in the program, monthly wage (in Shekels) and participation (yes/no) in non-employment activities such as educational, recreational and other leisure activities in the site ; and (d) the Quality of Life Questionnaire (QOL.Q) (Shalock & Keith, 1993). The scale total score (40 items) has a Cronbach alpha reliability of .84. A factor analysis yielded four factors: Satisfaction (items 1-10) with alpha=.75; Competence/Productivity (items 11-20) with alpha of .69; Empowerment/Independence (items 21-30), with alpha=70 ; and Social Belonging/Community Integration (items 31-40) with alpha=.79. Each item has 3-point scoring (1 lowest to 3 highest). The score for each scale can range from 10-30. A total score can be obtained from by adding the scores for the four scales. The scores may range from 40 to 120, with a high score meaning higher level of quality of life.

Procedure and Data Analysis

The researchers received a letter of approval from the Executive Director of the extended employment programs to study six extended programs in northern Israel. Each director of sheltered workshop received a letter specifying the procedure and a request for receiving consent form for each participant (including a guardian approval, if required). After receiving the filled consent forms, eight social work students interviewed participants in each site individually. They interviewed only the unmarried participants because they were 90 percent of the population. After the completion of data collection, all questionnaires were entered for statistical analysis. A Multiple Regression Analysis was used to test how much the independent variables contributed to Quality of Life (QOL) measures. Based on the literature review, the independent variables were entered in order, first the personal variables, than disability data and finally employment variables.

Findings

An early analysis of correlating between the independent variables with the outcome score showed that the participants' age (r=-.21; p<.03), perception of disability (r=-.42; p<.001) and whether they took part in non-employment activities, such as recreation and leisure (r=.22; p<.03) had significant correlation with the quality of life total score. Oneway Analysis of Variance between participants' type of disability and quality of life total score did not show any significant differences. A multiple regression analysis of the personal, disability and employment variables with the QOL total score (see Table 2) yielded a score of [R.sup.2] =.36.

A detailed analysis of the independent variables entered (first personal, than disability and last employment variables) with QOL total score showed that two independent variables were significant: Perception of severity ([beta]=-.397, p<.01) and degree of participation in non-employment activities (mainly social programs), [beta]= -.277; p<.0l). Participants perceiving their disability as mild and tended to participate less frequently in non-employment programs had reported greater QOL.

An analysis of the four factors of the Quality of Life Scale is presented in Table 3 (side by side). A multiple regression of the personal, disability and employment variables with satisfaction yielded a score of [R.sup.2] =.31. A detailed analysis of the independent variables entered showed that age ([beta]=-.221, p<.05), perception of severity([beta]=-.412; p<.01) and participation in non-employment programs (social programs) carried out in the site ([beta]=-.244, p<.01) were significant with satisfaction factor of QOL.

A multiple regression of the above independent variables with competence/productivity (the second factor of QOL) yielded a score of [R.sup.2]=.120. The specific analysis of the independent variables showed that only perception of severity ([beta]=-.212, p<.05) and participation in non-employment activities (mainly social programs) in the site had a [beta] of-.290, p<.01. A multiple regression of personal, disability and employment variables with empowerment/independence (the third factor) of QOL yielded [R.sup.2] of .24. Two independent variables were identified as significant with this factor: Living independently ([beta]=-.318, p<.01) and seniority in program ([beta]=-322, p<.01).

Finally, we carried out regression analysis of all independent variables with belonging/community integration (the forth factor) of QOL and found [R.sup.2] of .33. A detailed analysis of the personal, disability and employment variables showed four significant variables: Perception of severity ([beta]=-.297, p<.01); seniority in the program ([beta]=-.237, p<.05); monthly wage ([beta]=.222, p<.05), and participation in non-employment programs (mainly social programs) ([beta].=-.236, p<.05).

Discussion

Overall quality of life of single adults with severe disabilities working in extended employment programs in Northern Israel was not associated with their type of disability (physical, mental, intellectual or other) but with two significant predictors: Perception of severity of disability as milder rather than severe and by less frequent participation in non-employment activities such as recreational and leisure activities, carried out by the sheltered employment programs. Participants' who perceived their disability as milder and who tended to use the working site for only for employment and not for the non-employment activities (such as leisure and recreation) reported greater quality of life than those who lived in more protected housing, viewed their disability as severe and participated in non-employment activities in their extended employment program.

Although the average participant worked in the program more than five years, they tended to perceive quality of life as related to their non-employment environment. If quality of life refers to the person's desire for assimilation into society (Scherer, 1988), participants expressed their expectations beyond the sheltered employment program. Similar findings were identified in Freedman and Fesko's qualitative study on the meaning of work in the lives of people with significant disabilities (1996). The consumers, persons with significant disabilities, viewed their job outcomes and expectations as related to their personal goal settings rather than their current reality. They viewed their greatest obstacle in the stigma and societal attitudes toward persons with severe disabilities.

A detailed regression analysis for the total QOL score as well as the four factors: Satisfaction, competence/productivity, empowerment/independence and belonging/integration yielded interesting findings. The most frequent predictors of total score were the person's perception of his/her severity of disability as mild followed by less frequent participation in non-employment activities. These findings indicate that the person's quality of life has less to do with the participants' objective measure of disability (percentage of medical disability) or age but their subjective view of their own or desired function. This finding is consonant with Fabian's view that the subjective experience and not the objective situation is a more valid indication of how the person with disability experiences his quality of life (1992). Together with the second predictor, less frequent participation in non-employment program, it may express the participants' view that quality of life is the common expectation of those who perceive themselves are highly functioning and less involved in sheltered employment milieu (Freedman & Fesko, 1996).

Interestingly younger participants had greater satisfaction than older participants. This, in addition to seniority in the program, evident in the third (empowerment/independence) and forth (social belonging/community integration) factors, indicates that quality of life decreases with greater engagement with sheltered employment. Finally, participants saw their quality of life in social belonging/community integration (the forth factor) as related to high monthly wage.

Implications

These findings indicate that the Quality of Life Questionnaire is effective in identifying and understanding person's experiences in sheltered employment environments. Professionals should reexamine their views about participants in extended employment programs. They should be more sensitive to their experiences and desires to live and be accepted by society. The fact that persons with disability were assigned to extended employment programs does not mean that they have to stay there and be rejected from new experiences (Goode, 1992).

Our findings are quite encouraging as the needs and desires of Israeli single adults with disabilities participating in extended employment are similar to all persons with or without disabilities. Despite the fact that they spent years of their life in undesired employment setting they have similar dreams as other workers with disabilities and the non- disabled population.

There is a need to examine quality of life of participants in supported employment programs and to be more aware about changes that can occur in their quality of life during their transition from school to work or one work setting to another. In addition, it is recommended to include quality of life measure as part of the comprehensive evaluation of participants in extended employment programs.
Table 1: Participants' Characteristics (N=128)

 Characteristics Descriptive Data

Gender
 Male 72 (56.2%)
 Female 56 (43.8%)

Age (years)
 M 32.4
 SD 9.3

Living Independently
 Own Apartment 21 (16.4%)
 Semi-independent residence 20 (15.6%)
 Live with parents 87 (68.0%)

Years of Formal Education
 M 9.7
 SD 2.6

Primary type of Disability
 Physical 31 (24.2%)
 Psychiatric 33 (25.8%)
 Intellectual 33 (25.8%)
 Other 31 (24.2%)

Perception of Severity
 Mild 54 (42.2%)
 Moderate 40 (31.3%)
 Severe 34 (26.5%)

Percentage of Medical Disability
 M 391.7
 SD 313.1

Monthly Wage (in Israeli Shekels)
 M 413.9
 SD 259.6

Years of Stay in Sheltered Employment
 M 5.3
 SD 4.7

Table 2: Summary of Regression Analysis for Variables
Predicting of QOL Score (N=128)

Variable B SEB [beta]

Age -2.273E-03 .004 -.072
Live Independently -2.114E-02 .022 -.091
Medical Disability (in %) -5.128E-04 .002 -.022
Perception of Severity -.163 .040 -.397 **
Seniority (in years) -8.863E-03 .007 -.135
Monthly Wage (in Shekels) 1.838E-04 .000 .158
Non-employment Activities -.173 .058 -.277 **

Note. [R.sup.2]=.36

* p<.05

** p<.01)

Table 3: Regression Analysis for Four Factors of Quality of Life'

Factor Satisfaction Competence/
 Productivity

Variable B SEB [beta] B SEB [beta]

Age 9.61E-03 .005 -221 -5.759E-03 .005 -.135
 (P=.049)

Live 1.058E-02 0.31 .0343 .154E-02 .032 .105
Indepen-
dently

Medical 2.2203E-03 .003 .072 -1.645E-03 .003 -.055
Disability
(in %)

Perception -.224 .054 -12 -.113 .057 -.212
of Severity (P=.000) (P=.05)

Seniority 8.316E-03 .009 0.96 1.247E-02 .010 .147
(in years)

Monthly 5.292E-05 .000 .034 1.073E-04 .000 .071
Wage
(in Shekels)

Non- -.202 .080 -.244 -.235 .08 -.290
employment (P=.013) (P=.006)
Activities

 Note. [R.sup.2]=.31 Note. [R.sup.2]=.31

Factor Empowerment/ Belonging/
 Independence Integration

Variable B SEB [beta] B SEB [beta]

Age 5.343E-03 .005 -.118 -1.635e-03 -.006 -.031

Live -.102 .033 -.318 -2.886E-02 .036 -.079
Indepen- (P=.003)
dently

Medical 7.814E-04 .003 .025 -3.706E-03 .004 -.102
Disability
(in %)

Perception -.113 .058 -.200 -.192 .064 -.297
of Severity (P=.057) (P=.004)

Seniority -2.890E-02 .010 -.322 -2.433E-02 .011 -.237
(in years) (P=.006) (P=.031)

Monthly 1.631E-04 .000 .102 4.046E-04 .000 .222
Wage (P=.027)
(in Shekels)

Non- -1.639E-02 .086 -.019 -.231 .094 -.236
employment (P=.016)
Activities

 Note. [R.sup.2]=.24 Note. [R.sup.2]=.33


References

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Brown, L., Shiraga, B., York, J., Kessler, K., Strohm, B., Rogan, P., Sweet, M., Zanella, K., VanDeventer, P., & Loomis, R. (1984). Integrated work opportunities for adults with severe handicaps: The extended training option. Journal of the Association for Persons with Severe Handicaps, 9, 262-269.

Crudden, A., McBroom, L W., Skinner, A.L., & Moore, J.E. (1998). Comprehensive examination of barriers to employment among persons with visual impairment. Mississippi State University, Rehabilitation Research and Training Center for Low Vision, Mississippi State, MS 39762.

Dudley, J.R., & Struhsaker-Schatz, M. (1985). The missing link in evaluating sheltered workshp programs: The clients input. Mental Retardation, 23, 235-240.

Fabian, E.S. (1992). Supported employment and the quality of life: Does a job make a difference? Rehabilitation Counseling Bulletin, 36, 84-97.

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Griffin, D.K., Rosenberg, H., Cheyney, C., & Greenberg, B. (1996). A comparison of self-esteem and job satisfaction of adults with mild mental retardation in sheltered workshops and supported employment. Education and Training in Mental Retardation and Developmental Disabilities, 31, 142-150.

Inbar, L. (1998). Vocational Rehabilitation of Persons with Disabilities and Widows in Israel Periodical Report No. 157. (In Hebrew). Jerusalem: National Insurance Institute, Research and Planning Management.

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Mank, D. (1994). The underachievement of supported employment. Journal of Disability Policy Studies, 5, 1-24.

Moseley, C.R. (1988). Job satisfaction research: Implications for supported employment. Journal of the Association for Persons with Severe Handicaps, 13, 211-219.

Oleson, M. (1990). Subjectively perceived quality of life, Image, 22, 187-190.

Samony, E.L., & Waterpalse, L. (1992). Sheltered employment in the European Community. Council of Europe Publishing.

Schalock, R.L. (1990). Quality of life: Perspectives and issues. Washington D.C.: American Association on Mental Retardation.

Schalock, R.L& Kieth, K.D. (1993). Quality of Life Questionnaire manual. IDS Publishing Corporation.

Scherer, M. (1988). Assistive device utilization and quality of life in adults with spinal cord injuries or Cerebral Palsy. Journal of Applied Rehabilitation Counseling, 19, 21-28.

Stark, J., & Falkner, E. (1996). Quality of life across the life span. In R.L. Schalock (Ed.), Quality of life: Conceptualization and measurement (pp. 23-32). Washington, D.C.: American Association on Mental Retardation.

Thornton, P., & Lunt, N. (1997). Employment policies for disabled people in 18 countries: A Review. University of York, Social Policy Unit.

Wehman, P., Kregel, J., Banks P.D., Hill, M., & Moon, M.S. (1987). Sheltered versus supported employment work programs: A second look. Rehabilitation Counseling Bulletin. 31, 42-53.

Whitehead, C.W. (1986). The sheltered workshop dilemma: Reform or replacement. Remedial and Special Education, 7, 18-24.

Arie Rimmerman

University of Pennsylvania

Pro. Arie Rimmerman, school of Social Work, Center for the

Study of Youth Policy, 4200 Pine Street, 3rd floor, University of

Pennsylvania, PA 19104-4090.

Email: arik@ssw.upenn.edu

Richard Crossman

University of Pennsylvania
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Author:Crossman, R.H.S.
Publication:The Journal of Rehabilitation
Geographic Code:7ISRA
Date:Apr 1, 2004
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