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Consumers with major depressive disorder and employment outcomes: application of the theory of planned behavior.

Among U.S. citizens 18 years of age and older, approximately 45 million adults are diagnosed with mental illness (MI), of which 16.1% are identified as serious mental illness (SMI) (National Institutes of Mental Health, 2001; 2010). The MI disorders of MDD, bipolar disorder, schizophrenia, and obsessive-compulsive disorder are identified within the top 10 leading causes of disability in the U.S. and other developed countries. Major Depressive Disorder (MDD) is the leading cause of disability in the U.S. and established market economies worldwide (Murray & Lopez, 1996; National Institutes of Mental Health, 2001; Soleimani, Lapidus, & Isoifescu, 2011). Approximately 30.4% of the U.S. adult population is diagnosed with MDD. The prognosis for MDD includes impaired cognitive, social, and physical functioning. In the U.S., women are 70% more likely than men to experience MDD over their lifetime. When compared to persons over the age of 60 years, the likelihood of a diagnosis of MDD is 70% greater for 18-29 year-olds, 120% greater for 30-44 year-olds, and 100% greater for 45-59 year-olds (Elinson, Houck, Marcus, & Pincus, 2004; Fischer et al., 2000; Kessler, Berglund, Demler, Jin, & Waiters, 2005a; Kessler, Chiu, Demler, & Waiters, 2005b; National Institutes of Mental Health, 2011; Regier, Narrow, & Rae, 1993).

The development of innovative pharmacological agents has increased independent functioning among persons with MI, including those seeking employment, maintaining employment, and pursuing job mobility. However, in the U.S., less than 50% of the adults with MI receive adequate prescribed medical treatment. Among persons with MDD, only 37.5% receive adequate prescribed medical treatment; whereas the majority of persons with MDD continue experiencing significant limitations with independence, overall functioning, and well-being (Casacalenda, Perry, & Looper, 2002; Kessler et al., 2005a; Kessler et al., 2005b; Kuehn, 2011; National Institutes of Mental Health, 2011). For persons with MI, including MDD, employment has been correlated with increased self-esteem, independence, and overall functioning (Elinson et al., 2004; Finch & Wheaton, 1999; Kessler & Frank, 1997; Lehman et al., 2002; Narrow, 1998a; Narrow, 1998b; National Institutes of Mental Health, 2001).

In the U.S., the rate of unemployment for persons with MDD is 13.7%, compared to those without disabilities at 8.9%. For persons with MDD, barriers to job entry and job maintenance include lack of confidence, anxiety, level of social skills, lack of family support, gaps in work history, receiving Social Security Administration Supplemental Security Income, receiving Social Security Disability Insurance, social stigma, and workplace discrimination (Bureau of Labor Statistics, 2009; Bradley & Clemson, 2010; Hergenrather & Rhodes, 2004). Among persons with MDD, unemployment has been significantly correlated with several factors that include gender and residing in a non-metropolitan area (Substance Abuse and Mental Health Services Administration, 2009). Annually, the estimated lost productive time from employees with depression costs U.S. employers approximately $43 billion; of which 48.5% represents those employees with MDD (Adams, 2007; Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). Unemployment rates are correlated with severity of MDD and reported as 15.7% for mild MDD, 23.3% for moderate MDD, and 31.3% for severe MDD. Severity of the diagnosis of MDD has been significantly associated with level of treatment adherence, treatment access costs, MDD cyclical patterns of depression levels, disability status at work, and reduced work performance (Birnbaum, Kessler, Kelley, Ben-Hamadi, Joish, & Greenberg, 2010). Of the primary disability groups served by public vocational rehabilitation (VR) agencies, MI represents 20.2 % of consumers. As the second largest consumer population receiving public VR services, the placement of consumers with MDD in jobs remains challenging (Garske & Stewart, 1999; Rehabilitation Services Administration, 2002; Substance Abuse and Mental Health Services Administration, 2009).

To enhance employment outcomes of persons with disabilities, including those with MDD, research suggests exploring the impact of the attitudes of public rehabilitation placement professionals (PRPPs) toward the job placement of consumers with disabilities. The consumers' self-concept and self-efficacy to pursue employment have been significantly correlated with the attitudes of rehabilitation placement professionals (All, Fried, Ritcher, Shaw, & Roberto, 1997; Hergenrather, Rhodes, & McDaniel, 2005; Millington, Asner, Linkowski, & Der-Stephanian, 1996). The needs of consumers with disabilities demand that PRPPs provide services in an expert and efficient manner, to enhance job placement (Fabian, Luecking, & Tilson, 1995; Mullins, Roessler, Schriner, Brown, & Bellini, 1997). Through exploring the beliefs of PRPPs job placement outcomes for consumers with MDD may be enhanced.

Theory of Planned Behavior

In this study, the theory of planned behavior (Ajzen, 1988; Ajzen, 2001) was applied to develop the Major Depressive Disorder Placement Scale (MDDPS) and explore the factors associated with the job placement of consumers with MDD (see Figure 1). The theory of planned behavior (TPB) posits that a person's behavior is a function of his or her intention to perform a specific behavior (e.g., job placement of consumers with MDD). In the TPB, intention is determined by three factors: attitude, subjective norm, and perceived behavioral control. Attitude is defined as the individual's overall evaluation of the consequences or outcomes of performing the behavior (e.g., job placement of consumers with MDD). Attitude has two components: behavioral beliefs regarding the likely outcomes of the behavior (e.g., employment assimilates consumers with MDD into society) from performing the behavior and the corresponding outcome evaluation item about the value of the each outcome (assimilating consumers with MDD into society is good or bad). Subjective norm is defined as the social pressure an individual feels to perform, or not perform, a specific behavior (e.g., job placement of consumers with MDD). Subjective norm has two components: normative beliefs about the perceptions of important referents (e.g., workplace supervisor) to support, or not to support, the individual in performing the behavior and corresponding motivation to comply item (e.g., "Generally, I want to do what my workplace supervisor thinks I should do.") evaluating the likelihood of complying with the important referent. Perceived behavioral control is defined as the individual's perception of the extent to which the behavior (e.g., job placement of consumers with MDD) is perceived as being easy or difficult to perform. Perceived behavioral control has two components: control beliefs that identify an individual's perception of the likelihood of resources for performing the behavior (e.g., consumer family support for job placement), or impediments to performing the behavior (e.g., consumer's lack of job-seeking skills), and corresponding perceived power item to evaluate one's level of control over each resource (e.g., How much control do I have to improve the consumer's family support for job placement?) or impediment (e.g., How much control do I have to improve a consumer's job-seeking skills?) (Conner & Sparks, 1999; Kohler, Grimley, & Reynolds, 1999).

Behavioral change is the result of the change in behavioral beliefs, normative beliefs, and control beliefs that impact outcome evaluations (e.g., likelihood that job placement of consumers with MDD increases their self-esteem), motivation to comply (e.g. willingness to comply with my workplace supervisor), and perceived power (e.g., ability to increase consumer motivation to pursue employment) of persons (e.g., public rehabilitation placement professionals) performing the behavior addressed (e.g., job placement of consumers with MDD). When applying the TPB in research, Ajzen and Fishbein (1980) suggest data collection stages. In stage one, the behavior being studied must be identified, and the behavioral beliefs, normative beliefs, and control beliefs of persons most likely to perform that specific behavior (e.g., rehabilitation professionals) must be elicited. From the elicited beliefs, the modal behavioral beliefs, normative beliefs, and control beliefs, the modal would then be identified (Ajzen & Fishbein, 1980). Stage two addresses the development of a quantitative assessment (e.g., MDDPS) from modal beliefs, in which the each modal belief is paired with a corresponding evaluation item to create an assessment instrument. Both items are evaluated on a Likert scale. The psychometric properties of the assessment are then explored. This study addresses stage two of the data collection process. In stage three, the aforementioned assessment is provided to a sample of persons (e.g., public rehabilitation placement professionals) likely to perform the behavior being studied (e.g., job placement of a consumer with MDD) and a hierarchical regression is conducted to discriminate between persons who were successful, and those person who were unsuccessful, in performing the behavior. The results of stage three identify statistically significant differences in beliefs between the two groups, from which intervention strategies could be developed to create change in attitude, subjective norm, and perceived behavioral control; therefore impacting behavior (Ajzen, 1988; Ajzen, 2001; Ajzen & Madden, 1986; Francis et al., 2004).

Purpose of the study

The purpose of this study was to apply the TPB to explore the influences upon public rehabilitation placement professionals that impact the job placement of consumers with MDD. The MDDPS, developed by the authors and based on the Rehabilitation Professional Survey (Hergenrather & Rhodes, 2004; Hergenrather, Rhodes, McDaniel, & Brown, 2003), was applied to better understand the multidimensionality of job placement behavior of public rehabilitation placement professionals to place consumers with MDD. The fundamental research question posed was: Is the MDDPS a valid measure for public rehabilitation placement professionals when placing consumers with MDD in jobs? The authors addressed the following hypotheses:

H1: The placement of consumers with MDD in jobs is multidimensional.

H2: The attitude (AT) subscale is a valid construct of the MDDPS.

H3: The subjective norm (SN) subscale is a valid construct of the MDDPS.

H4: The perceived behavioral control (PBC) subscale is a valid construct of the MDDPS.

This study explores the application of the theory of planned behavior for the identification of strategies to increase the job placement of consumers with MDD.

Method

Participants

The study population was a convenience sample of public rehabilitation placement professionals in the Mid-Atlantic region of the U.S. Participants were recruited from the workplaces of 18 rehabilitation placement professionals enrolled in a research methods graduate course. Participation was voluntary. The selection criteria included being employed in a public vocational rehabilitation agency and an active consumer caseload within the past five years.

Of the 130 public rehabilitation placement professionals who were provided the MDDPS, 83.1% (n = 108) returned a completed instrument; suggesting a strong return rate. Participant characteristics included a mean age of 46.1 years, 98.1% (n = 106) were identified as rehabilitation counselors with a mean of 11.1 years placing consumers with disabilities in jobs, 72.2% (n = 78) held a master's degree, 51.9% (n = 56) reported certification as a rehabilitation counselor (CRC), 82.4% (n = 89) reported a general caseload, 55.7% (n = 59)were female, 62.6% (n = 67)were Caucasian, and 29.9% (n = 32) were African American. Among participants, 87.9% (n = 95) worked with a consumer with MDD on their caseload, and 67.6% (n = 73) attended an in-service training program on MDD (see Table 1).

Variables and Instrument

The MDDPS, an anonymous paper-pencil questionnaire, was developed to explore the relationship of the TPB constructs to the placement of consumers with MDD into jobs. The MDDPS was developed from the analysis of the Rehabilitation Placement Survey (RPS) (Hergenrather & Rhodes, 2004), in which 1,067 salient beliefs toward job placement of consumers with MDD were elicited from 86 PRPPs in the Mid-Atlantic region of the U.S. The analyses of the RPS identified nine modal behavioral beliefs, three modal normative beliefs, and ten modal control beliefs. The RPS modal beliefs had convergent validity, suggesting the alignment with the beliefs identified with the job placement of consumers with disabilities (Hergenrather et al., 2003), the job placement of consumers with a disability of substance abuse (Hergenrather & Rhodes, 2006), the job placement of consumers with HIV/AIDS (Hergenrather & Rhodes, 2008; Hergenrather et al., 2005), and the job placement of consumers with bipolar disorder (Hergenrather, Rhodes, & Gitlin, 2011).

The nine MDDPS behavioral belief items and nine corresponding outcome evaluation items, representing the construct of attitude, were based on the nine modal behavioral beliefs of the RPS (Hergenrather & Rhodes, 2004). Participants rated the likelihood of each of the nine beliefs of placing a consumer with MDD into a job (e.g., "For a consumer diagnosed with major depressive disorder, a job would structure in his or her daily routine.") using a seven-point Likert scale (7 = extremely likely, 6 = quite likely, 5 = likely, 4 = neither, 3 = unlikely, 2 = quite unlikely, 1 = extremely unlikely). Participants evaluated the value of the outcome for each of the nine behavioral belief items (e.g., "For a consumer with MDD, increasing structure in his or her daily routine is ...") using a seven-point Likert scale (3 = extremely good, 2 = quite good, 1 = good, 0 = neither, -1 = bad, -2 = quite bad, -3 = extremely bad).

The four MDDPS normative belief items and corresponding motivation to comply items, representing the construct of subjective norm, were based on the four modal normative beliefs of the RPS (Hergenrather & Rhodes, 2004; Hergenrather et al., 2003). Participants rated the likelihood each normative belief referent to support their performance of the behavior (e.g., "The family of a consumer with MDD think that I should place their family member into a job.") using a seven-point Likert scale (3 = extremely likely, 2 = quite likely, 1 = likely, 0 = neither, -1 = unlikely, -2 = quite unlikely, -3 = extremely unlikely). Respondents rated their motivation to comply each referent (e.g., "Generally speaking, I want to do what members of the consumer's family think I should do.") using a seven-point Likert scale (7 = extremely likely, 6 = quite likely, 5 = likely, 4 = neither, 3 = unlikely, 2 = quite unlikely, 1 = extremely unlikely).

The ten MDDPS control belief items and ten corresponding perceived power items, representing the construct of perceived behavioral control, were based on the ten modal control beliefs of the RPS (Hergenrather & Rhodes, 2004). Participants rated the likelihood of ten control beliefs (e.g., "A barrier to placing a consumer with MDD into a job would his or her lack of job-seeking skills.") using a seven-point Likert scale (7 = extremely likely, 6 = quite likely, 5 = likely, 4 = neither, 3 = unlikely, 2 = quite unlikely, 1 = extremely unlikely). Participants evaluated their perceived power/control over each control belief (e.g., "How much control do you have to increase the consumer's level of job-seeking skills?") using a five-point Likert scale (5 = complete control, 4 = a lot of control, 3 = some control, 2 = very little control, and 1 = no control).

Demographic items included job title, caseload, number of years employed as a PRPP, level of completed education, certification status, age, gender, and ethnicity. The MDDPS was validated for content, instrument development, and utility by three expert review panels: (a) four faculty members having experience in placing consumers with disabilities into jobs, (b) two faculty members having expertise in both the application of the TPB, and (c) a 12 PRPPs enrolled in a rehabilitation graduate program. The MDDPS was piloted with five PRPPs in the U.S. Mid-Atlantic region. Based on the expert review and pilot study, consensus was found, recommendations were reviewed, and minor changes were made. The MDDPS was approved by the Institutional Review Board of the first author's agency for the protection of human subjects.

Data Analysis

A deductive research approach was used, providing a direct focus using the TPB to conduct data analyses and identify meaningful measures (Burisch, 1984; Vogt, 1999). In using theory, a factor analysis was appropriate for validation of constructs (e.g., attitude, subjective norm, perceived behavioral control) (Pedhazur & Schmelkin, 1991). Because the sample size exceeded 100, a principal components analysis with varimax rotation was to explore the development of summated scales for attitude, subjective norm, and perceived behavioral control (Hair, Anderson, Tatham, & Black, 1998). The method accounted for measurement error and identified variance among variables (Velicer & Jackson, 1990). Analyses were conducted using PASW Statistics 18.0 (SPSS, 2009).

Results

Construct Validation

The data analyses identified three factors that represented the TPB constructs of attitude, subjective norm, and perceived behavioral control. In the final varimax rotation matrix of 13 items, six items loaded appropriately on factor one identified as Attitude; three loaded appropriately on factor two identified as Subjective Norm; and four loaded appropriately factor three identified as Perceived Behavioral Control (see Table 2). This was supported by the visual interpretation of the scree plot that identified three factors. The three factors accounted for 61.48% of the total variance and exceeded the 55% variance minimum criteria established by the authors to ensure the significance of the factors. The variance explained by the factors of Attitude, Subjective Norm, and Perceived Behavioral Control was reported as 31.40%, 16.29%, and 13.79% respectively. To ensure that the sample was adequate for statistical analyses, the Kaiser-Meyer-Olkin measure of sampling adequacy index (SAI) was .74, interpreted as good (Hair et al., 1998). Bartlett's test of sphericity, used to determine the appropriateness of a factor analysis, was highly significant at p < .001 suggesting that the factor analysis was appropriate (Hair et al., 1998; Maxwell, Cole, Arvey & Salas, 1993; Kim & Mueller, 1978; Nunnely, 1970).

The first factor, Attitude (AT), was a summated scale of six items that identified the outcomes of job placement for a consumer with MDD as increased social skills, increased self-esteem, increased work skills, assimilate consumers with MDD more fully into society, increased income, and increased structure in one's daily routine. The second factor, subjective norm (SN), was a summated scale of three items that identified the influential referents as the consumer's family, the workplace supervisor of the public rehabilitation placement professionals, and peer rehabilitation placement professionals in the workplace. The third factor, perceived behavioral control (PBC), identified the impediments to job placement of consumers with MDD as lack of family support, consumer's lack of job-seeking skills, consumer's level of motivation to become employed, and the medical instability of a prognosis of MDD.

The internal consistency estimate of reliability was computed for the MDDPS. Based on Loevinger (1954) criteria, Cronbach's alpha was good for the MDDPS (.89), excellent for the AT summated scale (.91), good for the SN summated scale (.73), and good for the PBC summated scale (.78). Construct validity was inferred from the significant correlations of the measures with theory constructs of attitude, subjective norm, and perceived behavioral control. AT was significantly correlated with SN (rs = .40, p < .01) and PBC (rs = .51, p < .01). SN was correlated with PBC (rs = .21, p < .05). The content validity of the scales was inferred from the elicited beliefs of public vocational rehabilitation placement professionals addressing each construct (Hergenrather & Rhodes, 2004).

Mean scores for each of the AT behavioral beliefs were reported as quite likely (range 5.75 to 6.07). The six AT outcome item means (range 1.48 to 1.98) were reported as quite good. Of the SN normative beliefs, those of "workplace supervisor" and "peer rehabilitation placement professionals in my workplace" were reported as quite likely (range 1.34 to 1.91) to support the job placement of consumers with MDD; whereas "consumer's family" was reported as likely (M = 1.29) to support the job placement of consumers with MDD. The SN corresponding motivation to comply item means reported that PRPPs were quite likely to comply with the "workplace supervisor" (M = 5.47) and reported as neither likely or unlikely to comply with both the "consumer's family" (M = 4.27) and "peer rehabilitation placement professionals in my workplace" (M = 4.22). The four PBC control beliefs were reported as impediments to job placement for consumers with MDD. The item means were reported as quite likely for "low motivation to pursue employment" (M= 5.73), "the medical instability of MDD" (M = 5.35), and "lack of job-seeking skills" (M = 5.31); and slightly likely for "lack of family support for the consumer to become employed" (M = 4.99). Of the PBC perceived power item, participants reported a lot of control "to increase a consumer's level of job-seeking skills" (M = 3.51); having some control to "influence the family to support the consumer's decision to work" (M = 2.77) and "increase a consumer's motivation to pursue employment" (M = 2.93); and having very little control in "stabilizing the medical instability of MDD" (M = 1.86).

Discussion

In this study, the MDDPS was applied to explore the factors influencing the intention of PRPPs to place consumers with MDD into jobs. The study extends beyond an attitude measurement scale, through identifying the value of behavioral consequences, social pressures, impediments, and resources for the job placement of a consumer with MDD. The analyses of the MDDPS identified a 3 construct 13 item measure with adequate psychometric properties. The subscales of AT, SN, and PBC had good or excellent reliability, convergent validity with the RPS (Hergenrather et al., 2004; Hergenrather et al., 2005), represented dimensionality, and conformed to the TPB (Ajzen, 1988, Ajzen, 2001; Conner & Sparks, 1999; Francis et al., 2004). The following study findings deserve highlighting and further exploration.

First, PRPPs rated all behavioral beliefs as quite likely and evaluated all as quite good for the consumer. This suggests that PRPPs are altruistic. Rather than being concerned for their own welfare, PRPPs are concerned with the welfare of the consumer, placing value on the consumer outcome as an ultimate goal (Batson, Turk, Shaw, & Klein, 1995). A common source of altruistic motivation is empathic emotion, in which one's feelings are congruent with the perceived welfare of the consumer. Outcomes of job placement for consumers with MDD addressed the consumer's needs; increasing the greater common good for all consumers and society in general (Batson, 1991; Hoffman, 1976).

Second, the construct of subjective norm suggests that PRPPs are influenced by the workplace environment when performing work-related behaviors. The workplace supervisor was reported as quite likely to support the placement of consumers with MDD in jobs and participants reported being quite likely to do what their workplace supervisor thinks they should do regarding placement; suggesting that PRPPs acknowledge that their ability to place persons with MDD in jobs is likely to be influenced by their supervisor. In most instances, people hold favorable attitudes toward behaviors they perceive referents (e.g., supervisors, managers) to support, and hold negative attitudes toward behaviors that they perceive those referents not to support (Ajzen & Fishbein, 1980). This aligns with Psychological Climate Theory, suggesting that individuals respond to environmental (e.g., workplace) expectations by regulating their behavior to realize positive self-evaluative consequences (e.g., job performance impact on annual appraisals) (Bandura, 1988; James, James, & Ashe, 1990). When a PRPP perceives that a referent (e.g., supervisor) believes that the job placement of a consumer with MDD is supported, the PRPP is more likely to perform that behavior. In most instances, people hold favorable attitudes toward the behaviors they perceive as supported by referents, and hold negative attitudes toward performing behaviors they perceive as unsupported by referents (Ajzen & Madden, 1986).

Third, PRPPs identified the four modal control beliefs (MCBs) as impediments to (e.g., low motivation to pursue employment, lack of family support for the consumer to become employed, lack of job-seeking skills, medical instability of a prognosis of MDD), rather than facilitators to, the job placement of consumers with bipolar disorder. When MCBs are identified as impediments, people are less likely to successfully perform the behavior when confronted with such impediments (Conner & Sparks, 1999). The fewer resources individuals believe they have to perform a behavior, and greater number of impediments perceived, the lower the likelihood that the behavior will be performed (Madden, Ellen, & Ajzen, 1992).

Finally, the medical instability of the prognosis of MDD was reported as being a barrier to the job placement of a consumer with MDD. The PRPPs reported having very little control to stabilize a consumer's medical prognosis of MDD. Research suggests that medical instability of MDD includes cyclical behavior, co-morbidity, and medication adherence. The MDD cyclical behavior pattern has been presented as of asymptomatic symptoms, a threshold depressive symptoms/minor depression, and severe depression; each associated with increments in psychosocial disability. The prognosis of MDD has been identified as chronic and pervasive but minimizes when a person is asymptomatic. Among persons with MDD, global ratings of psychosocial functioning regarding employment have both been reported as: "good" when the person is asymptomatic; "fair" when experiencing threshold level of depressive symptoms; and "poor" or "very poor" when experiencing severe depression at which the person is likely to experience severe impairments. When working with consumers with MDD, PRPPs could explore the consumer's understanding of the prognosis, identify cyclical patterns of MDD, discuss the impact upon workplace performance, and empower the consumer to request accommodations as needed (Hasin, Goodwin, Stinson, & Grant, 2005; Judd, et al., 2000). When planning for employment, it is imperative to have a well-informed Individualized Plan for Employment in which the PRPP has explored the medical history of a consumer with MDD, explored cyclical patterns, and identified co-morbidities.

Among persons with MDD, co-morbidities include panic disorder, generalized anxiety disorder, and personality disorders. Correlations between MDD and DSM-IV-TR (American Psychological Association, 2000) Axis I clinical disorders and Axis II personality disorders/ mental impairments have been reported as strong and significant (i.e., histrionic, antisocial, paranoid, schizoid, avoidant, and dependent). Persons diagnosed with MDD are likely to have reported at least one other anxiety disorder at an earlier age; suggesting that comorbidity among persons with MDD may be part of a larger depression/anxiety syndrome. MDD comorbidity has been correlated with dependence on substances (i.e., alcohol, drugs, and nicotine), rather than abuse of, with strong association for drug dependence. MDD has also been significantly correlated with chronic insomnia, by which sleep deprivation impacts one's ability to perform activities of daily living (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler, DuPont, Berglund, & Wittchen, 1999; Onyike, Crum, Lee, Lyketsos, & Eaton, 2003; Yang et al., 2011).

Among persons with MDD, medication adherence has been reported as poor. Even with complete adherence to a single prescribed MDD medication, remission rates when symptoms abate only occur in approximately 30% of persons with MDD. To increase remission, research suggests two prescribed medications, adhering to the first prescribed medication and being prescribed a second medication to delay response. In clinical trials, combination therapy has also been presented as providing superior clinical effectiveness in treating MDD and increasing remission (Blier, et al., 2009). Research presents several factors that impact medication adherence for persons with MDD. PRPPs can explore these factors with consumers with MDD on their caseloads. These include exploring the consumer's health beliefs toward taking medication (e.g., treatment for depression does not require medication), knowledge level of the purpose of the prescribed medication, knowledge of the side effects of the medication, and level of comfort with the prescribing physician's "bedside manner" (Rhodes, Hergenrather, Wilkin, & Wooldredge, 2009; Thompson, Peveler, Stephenson, & McKendrick, 2000).

PRPPS can also develop strategies to empower consumers with MDD to adhere with medication both prior to job placement and when employed. Consumer compliance could be enhanced through administering the Adherence Assessment (Smith, Rublein, Marcus, Brock, & Chesney, 2003) and the Medication Adherence Scale (Morisky, Green, & Levine, 1986) to identify areas impacting adherence. PRPPs could also model behaviors that have been successful for increasing adherence, through role play, in which consumers with MDD who adhere to prescribed medication model medication adherence behaviors for other consumers with MDD who have challenges with medication adherence (Conanan et al., 2003). Additional interventions that could be utilized by PRPPs to increase adherence include the application of cognitive behavioral therapy and structured interviewing to collaborate with the consumer to identify consumer support systems, increasing consumer knowledge of a diagnosis of MDD, exploring the consumer's attitude toward medication and diagnosis, and exploring the consumer's communication with their medical provider. PRPPs can also explore the consumer's knowledge of prescribed medication, including purpose, risks, benefits, and the effects of non-adherence on performing activities of daily living (Rhodes, Hergenrather, Wilkin, & Woolredge, 2009).

The results of this study suggest the MDDPS can be utilized by public and private vocational rehabilitation professionals, agencies, and organizations providing job placement to consumers with MDD. The MDDPS can be applied to identify perceived placement outcomes; the influence of the workplace supervisor, workplace peers, and the consumer's family on job placement of consumers with MDD; and explore job placement barriers and facilitators for consumers with MDD. When the placement of a consumer is perceived as unattainable due to a low value of placement consequences, limited support by a supervisor, workplace peers, and or the consumer's family; and limited control over impediments to job placement, then consumer placement is diminished. However, even with favorable beliefs, the evaluations of such beliefs may present as unfavorable and impede placement. Modifying the beliefs can create a positive change in attitude, subjective norm, and perceived behavioral control; increasing a person's ability to perform the behavior addressed (Ajzen & Madden, 1986; Conner & Sparks, 1999).

To enhance job placement for consumers with MDD, an initial step would be to identify beliefs (e.g., behavioral, normative, and control) and modify beliefs perceived as barriers to job placement (Fishbein & Ajzen, 1975; Fishbein & Middlestadt, 1989). Training interventions could include persuasive communication, in which the beliefs of PRPPs regarding the consequences of the job placement of consumer with MDD would be explored and challenged by PRPPs who have successfully placed consumers with MDD. Bandura (1986) recommends four ways to modify a person's beliefs associated with the performance of a behavior. These include personal experience by setting and achieving subgoals (e.g., ensuring that PRPPs have worked with a consumer with MDD on their caseloads), observing successes (e.g., identify PRPPs who have successfully placed consumers with MDD into jobs and those PRPPs model behaviors), standard persuasive techniques, and the use of relaxation techniques to enhance levels of comfort (e.g., to control feelings of anxiety associated with job placement of consumers with MDD). Instrumental to changing beliefs is the provision of positive reinforcement, which increases an individual's level of self-efficacy for performing the identified behavior (Bandura, 1988).

Limitations

The study findings must be interpreted within limitations. First, a convenience sample was used it may not be representative of PRPPs. Second, caution should be taken in making generalizations beyond the study population as the sample is limited in representation of Asian American/Pacific Islanders, Hispanic/Latino Americans, and American Indian/Alaskan Americans. Third, self-report measures may not translate into actual behaviors (Streiner & Norman, 1995). Fourth, self-reports may have been biased by social desirability concerns, "faking good", or a reluctance to answer questions relevant to job performance. Despite the limitations, the study provides a structure to identify the concerns regarding placement of consumers with MDD and suggests specific issues to address to enhance employment outcomes.

Conclusion

The MDDPS was introduced as an assessment to explore the influences upon PRPPs to place consumers with MDD into jobs. The results of the factor analysis supports research using a multidimensional measure to address the placement of consumers with disabilities, including those diagnosed with MDD (Fabian & Waugh, 2001; Strauser & Bevern, 2006). It is imperative that persons providing employment services to persons with MDD address these study findings to enhance placement. Further research should explore the correlation of the constructs of Attitude, Subjective norm, and Perceived Behavioral Control with the intention of PRPPs who have, and who have not, placed consumers with MDD into jobs. The application of behavioral theory to address the job placement of consumers with disabilities is an important component to further the empirical foundation of the rehabilitation counseling profession.

Figure 1: Theory of Planned Behavior. Adapted and modified from Ajzen and Madden (1986).

Attitude--perception of behavioral outcomes. Consists of:

Behavioral Beliefs--beliefs that the placement of consumers with major depressive disorder in jobs leads to likely advantages, and or disadvantages as outcomes of performing the behavior.

Outcome Evaluation--evaluation of outcomes of each behavioral belief as favorable or unfavorable.

Subjective Norm--influences on one's ability toward performing the behavior. Consists of:

Normative Beliefs--beliefs identifying those important referents perceived to influence, by being supportive or unsupportive, the placement of consumers with major depressive disorder.

Motivation to Comply--evaluation of one's motivation to comply with each referent.

Perceived Behavioral Control perception of difficulty in performing the behavior. Consists of:

Control Beliefs--beliefs identifying the resources for, or impediments to, placement of consumers with major depressive disorder.

Perceived Power--evaluation of one's power to access resources, and overcome impediments, to placement of persons with major depressive disorder.

Intention: To perform a specific job-related behavior.

Behavior: Job placement of consumers with major depressive disorder.

Acknowledgements

The authors would like to express their appreciation to the public rehabilitation professionals from Delaware, the District of Columbia, Maryland, Pennsylvania, West Virginia, and Virginia who participated in the study. We also thank Eleana M. Boyer from the Virginia Department of Rehabilitative Services for her consultation.

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Kenneth C. Hergenrather

The George Washington University

Eileen Haase

The George Washington University

Scott D. Rhodes

Wake Forest University School of Medicine

Kenneth C. Hergenrather, Ph.D., MSEd, MRC, CRC, Associate Professor, Center for Rehabilitation Counseling Research and Education, Department of Counseling and Human Development Graduate School of Education and Human Development, The George Washington University, 2134 G St. NW.; Rm. 313, Washington, DC 20037

Email: hergenkc@gwu.edu


Table 1
Characteristics of Participants (N=108)

Characteristic                               N (%)

Position
  Rehabilitation counselor               106 (98.1)
  Job placement specialist                 2 (1.9)
Caseload
  General                                 89 (82.4)
  Sensory Impaired                         9 (8.3)
  Transition                               8 (7.4)
  Other (e.g., general and transition)     2 (1.9)
Gender
  Female                                  59 (55.7)
  Male                                    47 (44.3)
Educational level
  Masters degree                          78 (72.2)
  Bachelor degree                         29 (26.9)
Certification
  CRC                                     56 (51.9)
  none                                    39 (3.6)
  CCM                                     10 (9.3)
  LPC                                      3 (2.8)
Ethnicity/race
  African American/Black                  32 (29.9)
  Caucasian/White                         67 (62.6)
  Hispanic/Latin American                  5 (4.7)
  Native American                          1 (0.9)
Other (e.g., bi-racial)                    2 (1.9)

Table 2
Rotated Factor Matrix

Item                                 AT     SN     PBC

1.  Increases social skills          .873
2.  Increases self-esteem            .851
3.  Increases work skills            .837
4.  Assimilates consumers with MDD   .832
    more fully into society
5.  Increases structure in one's     .729
    daily routine
6.  Increases income                 .719
7.  Peer rehabilitation placement           .799
    professionals in my workplace
8.  Consumer's family                       .691
9.  Workplace supervisor                    .633
10. Low motivation to pursue                       .734
    employment
11. Lack of family support for the                 .701
    consumer to become employed
12. Lack of job-seeking skills                     .699
13. Medical instability of MDD                     .656

Note. AT = attitude; SN = subjective norm; PBC = perceived behavioral
control.
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Date:Jan 1, 2013
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