Employment acquisition

Populations:

Asian

Outcomes:

Intellectual disabilities

NIDILRR Funded:

Research Design:

Mixed methods

Quasi-experimental

Peer Reviewed:

Yes

Factors affecting the likelihood that people with intellectual disabilities will gain employment

Authors:

Rosenheck, R. A. & Mare, A. S.

Year Published:

2005

Publication:

Journal of Intellectual Disabilities

Volume:

Number:

Pages:

9-23

Publisher:

Sage

Background:

People with intellectual disabilities have the lowest employment rates in society. (p. 9) There are many barriers both social and psychological that impact access to employment.

Purpose:

The study's purpose was to identify factors that may affect "the likelihood that people with intellectual disabilities will find employment through a supported employment agency". (p 9)

Setting:

The setting was a Supported Employment Agency in a large British city.

Sample:

The study sample was the files of 200 clients who had received services and most recently exited the agency.

Data Collection:

Routinely collected data was collected from the review of client records. Written descriptions of motivation when a client entered and left the agency were assessed and entered into a five-point motivation scale.

Intervention:

The intervention was Supported Employment services for individuals with intellectual disabilities.

Control:

There was no comparison or control group.

Findings:

When clients entered services, motivations levels averaged 3.8 based on the scale developed by the researchers. The average motivation when leaving the agency was 2.88. Clients who found employment had motivation levels of 3 or above when leaving the agency. There was a "significant association between motivation and outcome, referrer and outcome, and punctuality and outcome". (p. 19)

Conclusions:

The higher the initial motivation, the more likely the client was to gain employment.

URL:

http://journals.sagepub.com/doi/pdf/10.1177/1744629505049725

Disabilities:

Populations:

Outcomes:

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

What are the benefits of evidence-based supported employment for patients with first-episode psychosis?

Authors:

Rose J., Saunders K., Hensel, E., & Kroese, B. S.

Year Published:

2004

Publication:

Psychiatric Bulletin

Volume:

Number:

Pages:

281-284

Publisher:

Royal College of Psychiatrists

Background:

Early intervention services provide community-based treatment and support to young people with psychosis and their families, with an emphasis on maintaining normal social roles. The experience of psychosis can exclude a young person from a sense of autonomy, employment and youth culture. Young people aspire to social roles and goals: employment and education provide social identity and status, social contacts and support, a means of structuring and occupying time, activity and involvement, and a sense of personal. Quite apart from the money that can be earned, work tells us who we are and enables us to tell others who we are.

Purpose:

The purpose of the study was to examine the effectiveness of integrating evidence-based supported employment into an early intervention service for young people with first-episode psychosis. Demographic, clinical and vocational data were collected over a 12-month period to evaluate the effect on vocational outcomes at 6 months and 12 months of the employment of a vocational specialist, and to assess model fidelity.

Setting:

The Early Treatment and Home-based Outreach Service (ETHOS) is an early intervention service that has been in operation within South West London and St George‚ Mental Health National Health Service (NHS) Trust since June 2001. It provides a comprehensive package of community-based care for a maximum of 2 years to young people (aged 17-30 years) with a first episode of psychosis.

Sample:

The vocational specialist worked with all 40 patients within the service; 35 had a diagnosis of schizophrenia and 5 had diagnoses of other psychoses. The median age was 21 years with a range of 18-32 years.

Data Collection:

Data were collected from November 2001 to November 2002 for all patients who received vocational input. This information included:
‚Ä¢ demographic variables: age, gender, ethnicity;
‚Ä¢ clinical variables: primary diagnosis, duration of contact with the team, discipline of care coordinator.
Information on vocational status was collected on first contact with each patient and thereafter on a monthly basis.

Intervention:

A half-time vocational specialist was integrated into the ETHOS team to address the vocational needs of patients within the service. This specialist (K.M.) was an integral member of the multidisciplinary team but did not carry out care coordinator tasks. She coordinated all the vocational plans with the team, and worked directly with patients and their care coordinators to ensure that vocational goals were given a high priority. Direct client interventions included engagement, assessing vocational need, proactively helping patients to find (and keep) jobs and attend education courses, providing welfare benefits advice, addressing support needs and ensuring adjustments to enable patients to keep their jobs or remain in education. All patients within the service (n=40) received an intervention for 6 months, and 22 clients received it for 12 months.

Control:

There was no control or comparison condition.

Findings:

Following vocational profiling and input from the vocational specialist and the team, there were significant increases in the proportion of clients engaged in work or educational activity over the first 6 months of the intervention, and in a subsample over a second 6-month period. The evidence-based Supported Employment Fidelity Scale was used to measure the degree of implementation, which scored 71, signifying good implementation

Conclusions:

The results suggest that implementing evidence-based supported employment within an early intervention service increases employment and education opportunities for patients within the service. These results lend support for an evidence-based supported employment approach where vocational rehabilitation is integrated into the clinical team, to help people with severe mental health problems gain and retain employment and education. There is a national commitment to the development of early intervention services, and consideration needs to be given to the successful engagement and outcomes of young people with first-episode psychosis within services. If these young people aspire to social roles and goals, then helping them to gain and retain employment and education should not only improve longer-term outcomes but also provide a potential key to engagement.

URL:

http://pb.rcpsych.org/content/28/8/281

Disabilities:

Populations:

Outcomes:

NIDILRR Funded:

Research Design:

Mixed methods

Quasi-experimental

Peer Reviewed:

Yes

Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness

Authors:

Rinaldi, M., Mcneil, K., Firn, M., Koletsi, M., Perkins, R., & Singh, S. P.

Year Published:

2003

Publication:

The Journal of Nervous and Mental Disease

Volume:

191

Number:

Pages:

139-144

Publisher:

Lippincott, Williams and Wilkens

Background:

Supported employment is an evidenced based practice that assists individuals with mental illness with gaining and maintaining employment. One of the major barriers to work are disability payments offered by the Social Security Administration and the Veterans Administration. A few studies have shown that the amount of public income is negatively associated with employment, involvement with vocational rehabilitation services and income received from employment. There are no studies related to to the impact of disability benefits on employment of those individuals who receive intensive case management services.

Purpose:

The purpose of this study was to explore the relationship between income from public support, participation in Intensive Psychiatric Community Care and employment among veterans with severe mental illness.

Sample:

The sample included 520 veterans with severe mental illness who were randomly assigned to either IPCC or standard care. Prior to entering the study the majority or 87.5% were receiving at least one form of public payment. The average amount was nine hundred and fifty five dollars.
At the 12 month follow up interview, most of the sample 91.2%) were classified as non workers. There were few differences on baseline and demographic and mental health status. There was a significant difference between workers and non-workers on the amount of public income received in the month prior to baseline assessment, with non workers receiving more money.

Data Collection:

Demographic and mental health status were obtained through participant interviews at baseline and one year out. Symptom severity was measured using the Brief Psychiatric Rating Scale. Alcohol and drug use were examined using scores from the Addiction Severity Index. Functional status was assessed using the Global Assessment Scale. Fidelity to the IPCC Model was measured using the Dartmouth Assertive Community Treatment scale. A liberal measure was used to determine employment. In the data analysis, only composite scores were examined. Bivariate analyses were used to examine differences between demographic and mental health status variables. Multivariate logistic regression was used to look at the contribution of the independent variable.

Intervention:

The intervention was Intensive Psychiatric Community Care (IPCC).

Control:

The control condition was standard care.

Findings:

Public support levels were inversely related to employment. Symptom severity did not appear to be an independent barrier to work.

Conclusions:

Previous analyses of this study did not look at infrequent outcomes like employment. However, there is value in doing so as the results revealed the impact of assertive case management on employment outcomes.

URL:

http://www.ncbi.nlm.nih.gov/pubmed/12637839

Disabilities:

Populations:

Veterans

Outcomes:

NIDILRR Funded:

Research Design:

Quasi-experimental

Peer Reviewed:

Yes

The impact of employment counseling on substance user treatment participation and outcomes

Authors:

Resnick, S. G., Neale, M. S., & Rosenheck, R. A.

Year Published:

2004

Publication:

Substance Use & Misuse

Volume:

Number:

Pages:

2391-2424

Publisher:

Marcel Dekker

Background:

Employment Counseling (EC) is one of the more frequently received ancillary services in substance user treatment. Examining the impact of EC on treatment participation, post discharge abstinence and employment helps determine need for services and future study.

Purpose:

This article provides an analysis of the impact employment counseling has on individual‚ participation in treatment, post discharge abstinence and employment.

Setting:

The setting included various community mental health centers providing substance abuse counseling.

Sample:

A sub-sample of 988 adult clients discharged from 143 outpatient non- methadone substance abuse treatment facilities from the Alcohol and Drug Services Study was used.

Data Collection:

Data obtained from the treatment record abstracts and from interviews with the same clients were used in multivariate regressions that controlled for client demographic and background characteristics, facility characteristics, and characteristics of the sampled treatment episode. (pg. 2397)
Five dependent variables were examined: treatment participation, treatment duration, treatment completion, abstinence since discharge, and employment since discharge.

Intervention:

The intervention was substance abuse treatment with employment counseling as an ancillary service.

Control:

Clients were in two groups for comparison. One group had met-need for employment counseling. The second group had unmet need and did not participate in employment counseling.

Findings:

Clients with met need for employment counseling had longer treatment duration than those with unmet need (did not participate in employment counseling). There was no significant difference for treatment completion between the met-need and the unmet-need groups. Receipt of employment counseling has no impact on post discharge abstinence. Clients with met need for employment counseling were more than three times more likely to be employed at any time after discharge than clients with unmet needs. (p 2407)

Conclusions:

This study showed that clients who needed and received employment counseling have both better treatment participation and greater likelihood of employment after discharge than clients with unmet need. (p 2413)

URL:

http://www.ncbi.nlm.nih.gov/pubmed/15603009

Populations:

Outcomes:

NIDILRR Funded:

Research Design:

Intellectual disabilities

Peer Reviewed:

Yes

Predictors of post-high school employment among young adults with disabilities

Authors:

Reif, S., Horgan, C., Ritter, G., & Tompkins, C.

Year Published:

2002

Publication:

Career Development for Exceptional Individuals

Volume:

Number:

Pages:

25-40

Publisher:

Sage

Background:

Employment status is one of the most frequently researched outcomes following school exit for young adults with disabilities. Reported employment rates have been low, particularly for full-time employment. Factors related to transition success have also been investigated.

Purpose:

The purpose of this study was to examine data from the Alabama Transition Initiative related to student outcomes. The aim was to identify school, student, and program related variables that contributed to successful employment after school.

Setting:

The study settings were 37 of Alabama‚ 128 public school systems. These school systems served as the state‚ demonstration sites for its transition systems change project. They were selected through ATI‚ annual competition for transition mini-grants to enhance their transition programs through implementation of a set of best practices and participation in the Alabama Student Tracking System.

Sample:

The sample consisted of 1,393 former special education students from the participating school systems and who responded to a follow-up survey. The majority the sample members were male (67%) and Caucasian (52%), with 38% African-American. The largest disability group was those with learning disabilities (42%) followed by those with intellectual disabilities (20%).

Data Collection:

Data for this study were obtained through the Alabama Student Tracking System and a follow-along survey one year post school exit related to participation in employment, postsecondary education, and other adult activities. Data analysis was a hierarchical logistic regression analysis.

Intervention:

Control:

There were no control or comparison groups.

Findings:

The follow-up survey found that 73% of former students were employed one year following school exit. Employment outcomes were better for those who were male, with learning disabilities, from urban school systems. Related to the interventions, having a job at school exit was a significant predictor of post-school employment, but assistance from VR or MH/MI services were not.

Conclusions:

These findings suggest that students with disabilities can benefit from paid work experiences while in high school. In addition, females in rural settings need better transition planning and programs.

URL:

http://cde.sagepub.com/content/25/1/25.refs?patientinform-links=yes&legid=spcde;25/1/25

Disabilities:

Specific learning disabilities

Populations:

Transition-age youth (14 - 24)

Outcomes:

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

Developing evidence-based supported employment services for young adults receiving public mental health services

Authors:

Pryce, J., Munir, F., & Haslam, C.

Year Published:

2009

Publication:

New Zealand Journal of Occupational Therapy

Volume:

Number:

Pages:

34-39

Publisher:

Zealand Association of Occupational Therapists Inc.

Background:

Successful implementations of evidence-based supported employment for people with psychiatric disabilities are well documented in the USA. While international reports are informative, the differences among developed countries in terms of labour markets, health, and welfare systems, means that Australian and New Zealand experiences can best guide the introduction of evidence-based practices in the Australian and New Zealand contexts.

Purpose:

This report describes the application of an evidence-based practice fidelity measure to monitor the effectiveness of an expanding supported employment program for youth adults with first episode psychosis.

Setting:

The setting was 4 demonstration sites where employment staff co-located within an early intervention psychosis team.

Sample:

The study sample was made up of 134 individuals. Sixty four percent were diagnosed with first episode psychosis, and received services from a community based early intervention psychosis team.

Data Collection:

The IPS Fidelity scale was applied to each site. Data was collected and scored consistent with the Fidelity Scale directions.

Intervention:

The intervention was the Individual Placement and Support (IPS)model of supported employment. This is a systematic approach to helping people with severe mental illness achieve competitive employment. It is based on eight principles: eligibility based on client choice, focus on competitive employment, integration of mental health and employment services, attention to client preferences, work incentives planning, rapid job search, systematic job development, and individualized job supports. Systematic reviews have concluded that IPS is an evidence-based practice

Control:

Control conditions varied across the studies. Conditions included Group skills training, enhanced vocational rehabilitation, psychosocial rehabilitation, diversified placement, train-place, sheltered workshop, brokered vocational rehabilitation, and traditional vocational services.

Findings:

Both low and high scoring fidelity items helped identify practical ways to further develop evidence-based practices at each site.

Conclusions:

Fidelity strengths and weaknesses can be identified that have implications for other sites in terms of what employment consultants can most constructively do in context of the restraints of their immediate environment.

URL:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417652/

Disabilities:

Native Hawaiian / other Pacific Islander

Populations:

Male

Outcomes:

NIDILRR Funded:

Research Design:

Traumatic brain injury (TBI)

Peer Reviewed:

Yes

Investigation of factors related to employment outcome following traumatic brain injury: A critical review and conceptual model

Authors:

O'Brien, L.

Year Published:

2004

Publication:

Disability and Rehabilitation

Volume:

Number:

Pages:

765-783

Publisher:

Taylor & Francis Ltd

Background:

Employment outcomes post traumatic brain injury (TBI) result in a financial and social burden. In addition, unemployment may impact the individual's quality of life and emotional well being. The ability to predict vocational outcome using evidenced based guidelines can assist with rehabilitation planning, development of vocational support services and the role adjustment of the individual with a TBI and his or her family members.

Purpose:

A review of the literature to identify key variables associated with positive employment outcomes post TBI can pave the way for future research and the development of rehabilitation practices.

Data Collection:

Eighty five studies were identified between 1980 and 2003 that reported on factors associated with employment outcomes post TBI. Among those fifty studies met the inclusion criteria for the second stage review. The criteria used to evaluate and rate the quality of methodology for each study was adapted on guidelines by Sherer 2002 and Pengel et. al. 2003.

Intervention:

The review highlights demographic, injury and neuropsychological factors associated with return to work. It also examines interventions that focus on modifying the social environment in addition to emotional and metacognitive factors. A conceptual model is presented that outlines the factors associated with employment outcomes.

Control:

No control or comparison

Findings:

The most consistent predictors and indicators of employment outcomes included premorbid occupational status, functional status at discharge, global cognitive functioning, perceptual functioning, executive functioning, involvement in vocational rehabilitation services and emotional status. The authors note that although the presence of specific characteristics may be a predictor for failure to return to work the absence of a factor does not guarantee return to work.
There is little evidence to support cognitive rehabilitation. The most successful programs target problems with motivation and emotional disturbance. Interventions to modify the social environment need to occur on multiple levels. A person's preferences for employment impact job retention. Supported employment has been described however, further evaluation of outcomes is needed. At a policy level a major barrier exists in the current service delivery system in which individuals do not have access to long term rehabilitation or specialized vocational support. Changes in public policy and funding could improve service delivery. Developing disability management programs may also assist those at risk for chronic unemployment post TBI.

Conclusions:

The review of literature reported that the level of empirical support for employment outcome was greatest for: premorbid occupational status, functional status at discharge, global cognitive functioning, perceptual functioning, executive functioning, involvement in vocational rehabilitation services and emotional status. Future research is needed to determine the role of metacognitive, emotional and social environment factors that can be modified with various interventions. Interventions need to be evaluated to determine evidenced based practices.

URL:

http://www.ncbi.nlm.nih.gov/pubmed/15371049

Disabilities:

Populations:

Outcomes:

Systematic reviews and meta-analysis

Return to work

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

Methods of a multisite randomized clinical trial of supported employment amount veterans with spinal cord injury

Authors:

Ownsworth, T., & McKenna, K.

Year Published:

2009

Publication:

Journal of Rehabilitation Research & Development

Volume:

Number:

Pages:

919-930

Publisher:

Department of Veterans Affairs

Background:

Baseline data revealed that 65% of the study sample of veterans with spinal cord injury (SCI) who were seeking employment had never been employed postinjury. Nearly half (41%) of this group had received some type of prior vocational rehabilitation. This rate is consistent with veterans with SCI reported for samples in the community of individuals with SCI.

Purpose:

This article compares evidence-based supported employment (SE) with conventional vocational rehabilitation for veterans with SCI. The researchers hypothesis was that evidence-based supported employment when compared with conventional vocational rehabilitation will significantly improve competitive employment outcomes. The secondary hypothesis was that evidence-based supported employment for veterans with SCI would be more cost-effective than standard care.

Setting:

The study took place at multiple competitive employment sites versus standard vocational rehabilitation care at various Department of Veterans Affairs medical SCI centers.

Sample:

Veterans with spinal cord injury consisting of 95% males with an average age of 48.3 years. More than half of the subjects were white, 35.3% African American, 5% Hispanic.

Data Collection:

All subjects were followed for 12 months with face-to-face interviews every three months to collect data on primary employment variables and secondary outcomes measured. After this initial 12 months, the follow-up period was extended to 24 months at all sites including telephone interviews every three months. MANCOVAs were used to determine treatment group differences over time on the outcome variables (employment index, perceived barriers to employment, level of disability, quality of life, depression, and sustaining care needs), controlling for specified covariates. This included study site, sex, and age.

Competitive employment was as a primary outcome measure and measured every three months. Competitive employment is "community jobs that pay at least minimum wage (directly by the employer to the employee) that any person can apply for, including full-time and part-time jobs." General rehabilitation outcomes were measured at baseline and 3-month follow-up interviews. Standardized measures used included 1) Alcohol Use Disorders Identification test, 2)The Craig Handicap Assessment and Reporting Technique (CHART), 3) VR-36 that measures health-related quality of life in veterans, and 4) The Quick Inventory of Depressive Symptomatology Self-Report.

Demographic variables were also collected such as age, sec, race/ethnicity, employment history, previous levels of income, educational background, legal history, lifetime employment history, vocational services history, duration of SCI, level of SCE, and type of family structure.

Intervention:

The Spinal Cord Injury Vocational Integration Program uses the principles of evidence-based supported employment. The program integrates vocational services into the SCI continuum of healthcare. The SE principles include 1) integrated treatment, 2) rapid engagement, 3)competitive employment, 4) belief that success is possible regardless of severity or type of disability, 5) ongoing support, 6) veteran preferences, 7) community-based services, and 8)personalized benefits counseling. The investigators spent 4 to 6 months recruiting and hiring staff to provide the evidence-based SE services. All vocational rehabilitation counselors (VRCs) have master's degrees and are certified rehabilitation counselors. Training consisted of 3-day workshop taught by VA faculty. VRCs received ongoing instruction and coaching by a co-investigator who has more than 30 years experience in vocational rehabilitation (VR).

Control:

The study design was a randomized clinical trial that consisted of an experimental group and a comparison group. Interventional-site subjects were randomized to either the experimental group or the comparison group. Observational sites were selected based on similarity to the intervention site facilities with regards to subjects, communities, and VAMC culture. The observational sites were included because the researchers were considered that veterans and staff at the four intervention sites might be vicariously influenced by veterans and staff involved with the implementation study.

Findings:

The findings of this study were preliminary. The final enrollment count for the study was 301 subjects. At the time of this publication, 93 participants had reached study completion. Some of the challenges faced included exhausting the study pool earlier than expected, staff turnover, and slow process of culture change within the centers.

Conclusions:

This article discussed the methods of an ongoing randomized clinical trial of VR approaches among veterans with SCI. Strengths of the study design include repeated measures to evaluate employment across time, inclusion of benefits-counseling, and ongoing fidelity monitoring of the treatment conditions. Before the study, the researchers concluded that there was a lack of attention to identifying or addressing vocational issues in the treatment setting. A culture change occurred such that providers began to introduce and explore the topic. In this study, the recruitment relied on clinical providers' willingness to broaden their definition of rehabilitation to include vocational issues. The preliminary baseline data from this sample showed that the majority (72%) had never been employed postinjury.

URL:

http://www.rehab.research.va.gov/jour/09/46/7/Ottomanelli.html

Populations:

Older workers (55+)

Hispanic or Latino

Veterans

Outcomes:

Randomized Controlled Trials (RCTs)

Full-time employment

Part-time employment

Wages

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

Effectiveness of supported employment for veterans with spinal cord injuries: Results from a randomized multisite study

Authors:

Ottomanelli, L., Goetz, L., McGeough, C., Suris, A., Sippel, J., Sinnott, P., Wagner, T. H., & Cipher, D. J.

Year Published:

2012

Publication:

Archives of Physical Medicine and Rehabilitation

Volume:

Number:

Pages:

740-747

Publisher:

Elsevier

Background:

Unemployment for individuals who have sustained a spinal cord injury is a serious problem. Ottomanelli et al report that the average rate of paid employment for individuals post SCI is approximately 35%. The rate of individuals returning to work post injury has been cited as even lower at only 12% returning to their preinjury jobs. In 2004, the Veterans Health Administration implemented an initiative to apply evidence-based supported employment to veterans with serious mental illness (SMI). This article is one of the first multisite, randomized controlled trials of supported employment versus standard vocational rehabilitation care for veterans with spinal cord injury (SCI).

Purpose:

The purpose of this research was to examine whether supported employment is more effective than "treatment as usual" in returning veterans to competitive employment after spinal cord injury.

Setting:

SCI centers in the Veterans Health Administration. Sites were selected based on location in a metropolitan geographic region, adequate economic and industrial development, strong management and leadership support at the medical center, available subject pool, and existing public transportation system.

Sample:

A total of 201 Veterans with a spinal cord injury between the ages of 18 and 65 who received medical and/or rehabilitation health care services at 1 of the 6 participating VA Medical Centers were included in the study. Only veterans who were not employed, or were employed earning less than the level of substantial gainful activity as by Social Security were included in the study.

Data Collection:

The main outcome measure was competitive employment in the community. Data was collected through subject interviews, chart extraction of sociodemographic information, medical and psychiatric information, Social Security benefits. Veterans were assessed using the Veterans RAND 36-item Health Survey, Quick Inventory for Depressive Symptomatology - Self-Report, and Craig Handicap Assessment and Reporting Technique. In addition, the IPS Fidelity Scale was used to measure the adherence to the SE model.

Power analysis pre study indicated that a total of 126 subjects were needed. Statistical analysis on the data included Student t test or Wilcoxon rank-sum tests, the Pearson chi-square test or Fisher exact test where appropriate. Effect sizes calculated for employment outcome data included rate ratios, and Cohen's d for continuous data, and Cramer's v for categorical data where appropriate. Analyses were performed with SAS version 9.2.

Intervention:

The intervention consisted of a supported employment vocational rehabilitation program called the "Spinal Cord Injury Vocational Integration Program." This program was designed to "adhere as closely as possible" to the evidence-based supported employment model for individuals with mental illness.

Control:

Subjects were randomly assigned at the intervention sites to the supported employment(SE) condition or the treatment as usual-interventional site (TAU-IS). In observational sites where there was no SE program veterans were enrolled in a nonrandomized TAU condition.

Findings:

Veterans in the SE group were 2.5 times more likely than the treatment as usual group-interventional site and 11.4 times more likely than the treatment as usual-observation site group to obtain competitive employment.

Conclusions:

Supported employment as a well-prescribed method of integrated vocational care, was superior to usual practices in improving employment outcomes for veterans with SCI.

URL:

http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1189&context=publichealthresources

Outcomes: