Date of Degree
Doctor of Public Health (DPH)
Community Health and Social Sciences
Emma K. Tsui
Jen Yung-Chen Chiu
Infectious Disease | Public Health | Public Policy | Vocational Rehabilitation Counseling
HIV/AIDS, Peer Programs, Client-Focused Considering Work Model, Work Readiness Interventions, Employment Preparedness, HASA
Medical advancements in HIV care should have reduced barriers to employment for PLWH, yet in 2017 only 47.7% of PLWH reported being employed, as compared to 62.9% in the general population. Employment is a significant social determinant of health, it impacts a variety of factors related to health, including earned income, access to healthcare, and social connectedness. Quantitative and qualitative studies have identified several concerns PLWH have about entering the workforce; the most pressing being fear of losing benefits. Targeted work readiness programs for PLWH is an important approach to help PLWH overcome their unique barriers to work, such as the psychosocial impact of years of unemployment/no work experience, adjusting to independence from entitlements, navigating disclosure, confidentiality, properly using leave time, and negotiating reasonable accommodations.
Goldblum and Kohlenberg (2005) developed a theoretical model to be utilized in vocational development programs for PLWH who are considering reentering or entering the workforce called the, “client-focused considering work model for people living with HIV.” The model applies Prochaska and DiClemente (2005) Stages of change to the phases of considering work (contemplation, preparation, action, resolution). Additionally, it emphasizes the importance of weighing the impacts of returning to work on the medical, psychosocial, financial/legal, and vocational domains of influence. The model is client focused and stresses that the decision to work is made by the client; choosing not to work does not suggest failure.
Some people living with HIV participate in part-time peer work with AIDS Service Organizations. This allows them to experience the positive aspects of work without some of the fears of full-time work. Peer educators have been incorporated into HIV treatment and prevention programs since the inception of the HIV epidemic. Peer workers provide a variety of services including, health education, psychosocial support, case finding, community outreach, navigation to medical appointments, and treatment adherence. Participating in a peer program is a possible gateway into full-time employment.
This dissertation sought to examine a peer workforce development program in New York in order to: 1) update knowledge on barriers and facilitators to work for PLWH, 2) understand who workforce development programs should be targeting in order to maximize the employment of PLWH, 3) test the impact of workforce development on psychosocial outcomes of PLWH, and 4) tailor the Client-Focused Considering Work Model to HIV peer programs. The results of three papers are provided.
Paper 1 was a secondary data analysis of the peer program’s December 2018 evaluation survey. The survey combined various validated measures and demographic questions assessing health, work and psychosocial outcomes of participants. A forced entry hierarchical logistic regression analysis was used to assess which demographic, work history, benefits received, and activities were associated with peers wanting to enter full-time employment. Additionally, to determine the associations between the desire to seek full-time employment in the next year and work preparedness activities performed, chi-square tests were conducted.
Paper 2 was a longitudinal evaluation of the peer training and internship program. The studied peer program involved an 8-week peer training component and a 6-month internship. Participants took an evaluation survey on the first day of the training program, on the last day of the training program and after 6-months of internship. From September 2014 through December 2018, nine cohorts of peer training participants were followed through the end of their six-month peer internship. Emotional psychosocial outcomes (depression, HIV internalized stigma, and self-esteem) and behavioral psychosocial outcomes (medication adherence, patient self-advocacy, and safer sex communication apprehension) were measured in this study. Paired t-tests were performed to determine if significant score changes occurred at the individual level between surveys.
Paper 3 utilized results from five focus groups to describe the experiences of participants in an HIV peer program in New York City through the lens of Goldblum and Kohlenberg’s “client-focused considering work model for PLWH.” An interview guide was created from a review of the literature and developed through the lens of the client-focused considering work model for PLWH. To help facilitate focus group conversations participants completed a “barriers to work” survey before each focus group. Focus groups were semi-structured, the interview guide served as a baseline and was adapted and expanded as needed. A four-stage thematic analysis of transcriptions occurred. Themes were identified utilizing a theoretical approach at the semantic/explicit level.
In Paper 1 seventy-six individuals living with HIV completed the evaluation survey. Approximately 54% of participants (n = 41) reported a desire to work full-time in the next year. The final step of the hierarchical regression model tested the impact of demographic, social security benefits received and work history variables on a desire to work full-time in the next year. Having received social security benefits was significantly associated with a desire to work full-time in the next year. As compared to those not having received social security benefits, participants having received benefits had 0.20 times the odds of wanting to work full-time in the next year (95% CI = .05-.84, p < .03). Education retained significance, those with a high school diploma had 11.25 times the odds of a want for full-time work in the next year as compared to those who did not (95% CI = 1.29-98.35, p < .01). There was a significant association found for the number of work preparedness activities completed. Chi-squared tests of independence were calculated to compare work preparedness activities by desire to work full-time in the next year. Significant associations were found for updated resume in the past six-months and applied for a full-time job. Twenty-nine percent of those who reported wanting full-time employment in the next year had applied for a job in the past six-months as compared to 3% of those who did not report wanting full-time employment. Sixty-eight percent of those who had a want for full-time employment in the next year had updated their resume in the past six-months as compared to 29% of those who had not reported wanting full-time employment.
In Paper 2 137 PLWH completed the training program and 55 individuals completed both the training and 6-months of internship. Participating in the peer training program significantly decreased the measured emotional psychosocial scores of depression (p < .001) and internalized HIV stigma (p < .001). Only participants who went on to complete six-months of internship had significantly improved behavioral psychosocial scores at the end of training course, including a decrease in safer sex communication apprehension (p < .001) and an increase in HIV medication adherence (p < .02) and patient self-advocacy (p < .02). Training only participants had an increase in self-esteem (p < .001) at the end of training and internship participants had an increase in self-esteem only after internship (p < .01). For internship participants, all other measures significantly continued in the hypothesized direction at the end of internship, except for HIV medication adherence.
In Paper 3 the analysis explored if peers’ experiences of considering work fit the client-focused considering work model and refined the model to reflect peers’ perspectives and tools used in typical peer programs. Added to the model were tools utilized by peer programs to help improve the self-esteem and self-efficacy of peers, as well as tools that assisted peers during their full-time employment decision making process. Additionally, the authors described the barriers and facilitators to full-time work as perceived by participants for each domain of influence (medical, financial/legal, psychosocial, vocational concern, vocational confidence).
Conclusion: Overall, this dissertation demonstrates that participating in an HIV peer program inclusive of peer support services has positive psychosocial and professional development impacts on the participant. Focus group participants experienced barriers to full-time work including, loss of benefits, episodic disability, opportunities at a livable wage, and suitable leave time. Most focus group participants were partaking in vocational intermediary steps, such as peer certification courses, but not activities directly related to employment. An association was found for wanting full-time employment in the next year for peers who were not receiving SSI/SSDI and those with at least a high school diploma, but not for other demographic, benefit, and work history variables. Peer work may not be a gateway to full-time employment for all peers, but it does build self-efficacy and self-esteem. Peer programs should be based in theoretical models that shape program evaluation, measured evaluation items must include employment mediators, intermediary steps and employment outcomes. The client focused considering work model for PLWH was tailored to meet the needs of HIV peer programs. The tailored model provides strategies for peer program development, implementation, and evaluation.
McKinney-Prupis, Erin R., "Psychosocial impacts and employment preparedness of participating in an HIV peer program: Implications for tailoring a vocational counseling model for PLWH" (2020). CUNY Academic Works.