Unemployment impacts the financial security and independence of the individual. There is also a cost implication for society, with patients who become more dependent upon the state, requiring more financial support. The majority of state support is related to the increased disability in the unemployed group, which necessitates a higher level of care and mobility support. However, a proportion of these costs would fall if patients were able to return to employment.
Ansell and Wood (26) found that 83% of 243 patients were in education, employment or married and running a home at 15 years follow-up. Miller (64) followed up 44 patients for an average of 16.1 years and showed that patients received a similar level of education to their siblings and the local population. Poor physical function was more common in those adults staying in education or becoming "homemakers," compared to those entering the workplace.
The employment rate tends to fall, with longer follow-up periods. Foster (67) found that 21% of 180 patients at 18.7-years follow-up were unemployed, despite good academic attainment. David et al. (2) studied
43 patients with a mean disease duration of 19.7 years. Sixty-six percent of patients were employed, but 30% were not working as a direct result of their disease. Peterson et al. (5) reported in a cohort study performed on
44 patients with an average follow up of 24.7 years, that they had similar educational achievement to controls, but a significantly lower level of employment (70.5% vs. 87.3%). In their cohort, Oen et al. (67) showed that the overall unemployment rate in JIA was similar to the general population, but the rate in the 20 to 24 age group was significantly increased. This might suggest that young adults with JIA find it harder to initially enter the workplace at a key time in career development.
Packham and Hall (62) described a 28% unemployment rate in 246 patients with an average disease duration of 28 years. Despite being a well-educated patient group, unemployment was much higher than in the general population. The majority of patients without work attribute their unemployment to the disabling effects of their disease. Physical disability is not as severe in employed patients compared to those without work. The unemployed patients who had never entered the workplace tended to be less disabled than those who could no longer work, suggesting the factors that govern successful transition from education to employment are not solely related to physical ability. Poor educational achievements and limited physical function predict unemployment as one would expect, but the presence of poor coping strategies also correlates strongly with unemployment. This suggests that an individual's ability to successfully cope with their arthritis has a large impact on their success in entering competitive employment.
Appropriate vocational planning and support can facilitate the transition from school to work in adolescence. White and Shear (69) reviewed a group of 242 patients (72% with JIA) who had been given specific prevoca-tional assistance. They reported an employment rate of 72% with a further 15% of patients still attending university. The unemployment rate was just 6%, while 6% were full time housewives and mothers. Twenty-seven percent completed university compared to just 7% of the control population.
Many individuals feel that they are discriminated against at work (62). Discrimination is by nature subjective, enmeshed irrevocably with the perceptions patients have of the environment they live in. If an individual feels he has been discriminated against, it does not necessarily follow that the events leading to that perception were discriminatory. Conversely, the unthinking actions of others may amount to discrimination by omission. Most workplace discrimination occurs around job interviews, with problems split between a failure to be interviewed initially and a perception of unreasonably high levels of failure once interviewed. Once in a job, discrimination tends to be more covert, with access problems and delays in promotion predominating. Only a small proportion of people experience overt negative or discriminatory attitudes towards them. If discrimination does occur, it often originates from direct superiors, rather than being institutional in nature.
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