New Zealand Rehabilitation Association, Inc.

I like these guys because they cite me. I figure that is the sort of thing you can say in a blog that you could never get away with writing in a peer-reviewed journal article, so I just wanted to get that out of the way first. ;-)

Tsaouside and Ashman have conducted a study looking in detail at the relationship between the perceived importance of work, achievement of return-to-work and improvements in various aspects of health status in a population of people with traumatic brain injury (TBI). This is an important area of research because historically return-to-work has tended to be used as a universal measure of ‘success' following rehabilitation for people with TBI. The assumption has been (and, to be fair, this has been borne out to a certain degree by empirical research) that return to full time paid employment results in improvement in quality of life (QOL) for people with TBI. However, the relationship between work and QOL after TBI can be moderated by a variety of other factors, including whether or not the work results in feelings of productivity and the impact of work on maintenance of health and well-being in other aspect of life (such as home life and relationships).

Tasousides and Ashman conducted a cross-sectional study involving 317 adults, aged 18-65 years, who were living in the community with a diagnosis of TBI. They collected data on changes in work status since injury, on quality of life (using the Life-3 questionnaire), on psychological well being, and on depression (using the Beck Depression Inventory-II). They also measured ‘Work Discrepancy' which they operationalised on a 12 point scale as the difference between the perceived importance of work (using the work component of the Flanagan Scale of Needs) and the degree to which that need was met. Using regression analysis the authors were able to demonstrate a small but statistically significant relationship between work discrepancy, quality of life, and depression. The point here is that quality of life and depression is not only associated with whether or not people with TBI obtain employment, but appears to also be mediated by their perceptions regarding the importance of having work after injury and the degree to which this need is or is not fulfilled.  In other words, some individuals might consider paid work as an important aspect of their life, in which case achieving paid work is going to have a large effect on their QOL and failure to attain employment is likewise likely to have a more significant impact on reducing QOL than for someone who does not value paid work as much.  Therefore, measures of ‘success' regarding vocational rehabilitation should not only involvement objective measures of outcome (such as work placement and dollars earned) but also should include subjective indicators of the degree to which the work placement (or not) matches that individual's work needs and goals. 

Of course, there are other reasons for funders of health services to prioritise return to work as a goal of rehabilitation - it is after all the path towards getting claimants 'off the books'.  However, surely there is a difference between just having a job and attaining meaningful employment.  The cost-effectiveness of vocational interventions should be judged by the latter rather than the former - and Tsaouside and Ashman's (2008) paper provides some empirical evidence to back this assumption up.