*Corresponding Author:

Peggy B. Smith, Professor and CEO

Population Program Baylor College of Medicine One Baylor Plaza, Houston. TX 77030, USA, Tel: 713-873-3603;

E-mail: Peggys@bcm.edu

ABSTRACT

Abstract: Minority low-income post-secondary young women often manifest behaviors that make them at risk for unemployment. Emphasis on Social Determinants of Health (SDOH) suggests that jobs foster important non-medical health improvement via meaningful work. Work force programs facilitate employment and a next step is to address job retention. Employment procurement and continuation of 37 adolescent and young adult women who completed course work/practicum for health professions were assessed. We attempted to answer the following: What are the behavioral factors subsequent to hiring that influence job retention; Can program linkages and equity strategies mitigate negative forces. Finally, can a program linked to a medical home, address risk components that affect job retention?

Methods: Data analysis used two methodologies to evaluate retention outcomes. First, for qualitative assessment, content analysis documented the internal validity and reliability of job retention themes. Quantitative measures calculated the prevalence and scope of risk factors and their impact on program retention.

Results: Of the followed participants, only 10 or 27% were hired and still employed 4 to 6 months later. Findings suggest that participants even with stable employment had to overcome chronic negative SDOH that had the potential to affect job retention.

Conclusions: The assessment identified chronic housing, financial, transportation and personal relationships that had the potential to impact job retention, many of which were identified at initial enrolment. Follow up data also suggests that linkages to professional social support from therapists should be maintained subsequent to hire address potential behaviors that do not support work force expectations. To maximize success for underserved women linkage to the program’s medical home provides a trusted job portal and is easily accessible to mitigate situational risks to job retention and to receive primary preventive medical care.

Key Words: At- risk behaviors, work retention, social determinants, minority women, post-high school employment.

INTRODUCTION

Social Determinants of Health (SDOH) have emerged in the last decade as a powerful non- medical influence on individual and societal health. Underserved populations such as minority women are especially vulnerable to these forces and can be independent of medical care [1]. Building on this research, public health professionals have drawn increasing attention to a variety of non-health factors and their associated behaviors that contribute to the behavioral, physical and economic well-being of groups experiencing some form of disparity. From a behavioral health and psychiatric perspective [2] some suggest that poor and disadvantaged populations are often affected by mental disorders, and that cumulative stress of social determinants of health play a role in these conditions across the lifespan. Wang, Glazer, Howell, & Janevic [3] in their systematic review state that Social Determinants of Health impact the delivery of reproductive health care. The authors posit that women, residing in marginalized or low-income zip codes, were more likely to have emergency department visits within 90 days of delivery. Economic circumstances are also identified by a variety of other disciplines [4] as powerful influencers on health, homes, neighborhoods, schools, and workplaces and can have decisive impacts on wellbeing [5]. Others suggest that adversities in childhood have a negative impact on numerous adult health outcomes and behaviors including premature death, adolescent pregnancy, and illicit drug-use which all impact job acquisition and retention. Flaherty et al. [6] also propose that the timing of adverse experiences during adolescence and young adulthood may provide important information about pathways between ACEs (adverse childhood experiences) and the ability to hold a job. Resiliency theory can also provide an early and antecedent perspective on how employment success and adverse circumstances, especially its components are related [7-9]. Resiliency, as described, represents a constellation of characteristics that enable underserved individuals to positively adapt to the circumstances they encounter [10]. Resilient individuals are often characterized by a sense of optimism, curiosity, and the ability to personally detach and objectively conceptualize problems. These traits are often referred to as protective factors, which may modify, ameliorate, or alter a person’s response to environmental hazard that predisposes to a maladaptive outcome [11]. The identification of these protective factors supports the view that resilience affects how various individuals respond to adversity and may also provide an underlying rationale for the relationship between Social Determinants of Health and job acquisition and retention. Attitudes and competencies such as the ability to form relationships, solve problems, and future orientation [12] are the outcomes of this resiliency and may be useful in the workplace . Especially for the women, this may translate into the ability to not take personally the adversity in their life, not to see adversity as a permanent condition and not to see setbacks on the job as pervasive. Moreover, this model suggests that when resilient youth especially women, have some control over their life, and have positive things to do including school attendance, community involvement, avoidance of negative health behaviors, they are able to reduce impediments to future employment.

While many interventions may focus on a single social determinant as their primary target, they also are likely to have ripple effects across various social determinants. For example, some suggest [13] that an affordable housing intervention supplemented by livable wages moves families into lower poverty neighborhoods and are likely to improve access to better school and neighborhood conditions such as robust academic schools, neighborhood playgrounds and community walking trails.

Employment and job acquisition offer similar interrelationships and are strongly associated with nonmedical factors affecting health for the general population and youth [14]. Several authors [1] suggest that health is also influenced in part by employment factors such as workplace safety, job security and upward job mobility. This theory may help explain that young adults who are employed may be healthier than those who are not [15]. Some authors [16] go so far to suggest that employment and its associated infrastructure can have a more powerful impact on health via effects on health resources and the reduction of chronic stress. They conclude from their review of policies generated by the Civil Rights movement that subsequent equal access to employment and medical care led to increases in life expectancy between the mid-1960s and the mid-1970s, especially among minority groups. Others (2) also report employment interventions for specific vulnerable groups, including low socioeconomic status women, could be effective in reducing physical and mental health disparities in these populations.

Implications from the variety of social determinants of health factors have a special relevance to at-risk inner-city adolescent and young adult women whose physical health and economic future are often affected by the factors described above. Many minority high school women graduates are less likely to attend college but can especially benefit from addressing adverse life experiences and the practical components of the social determinant of work, the interconnectedness of work and socioeconomic and health status. Job acquisition and a clear career path for this cohort can provide a living wage as well as a modification of behavioral and legal risk factors, including sexual risk behaviors that occur during young adulthood which can shape subsequent health and economic outcomes. There are additional secondary benefits to the individual and community. Employment especially job retention for adolescents and young adult women is important, as it provides access to health benefits contraception, and employer supported wellness incentives and programs.

This paper therefore evaluates strategies to enhance employment retention for a cohort of young minority women subsequent to work force program training, hiring and initial employment. In examining participant job continuation, this assessment attempts to answer the following questions. First, what are the behavioral factors subsequent to recruitment and hiring that influence job retention. Second, can the proposed approach of linking job training and social support enhance positive factors and mitigate negative forces subsequent to employment. Finally, can a medical home provide a trusted job portal and mitigates situational risks to job retention? We also propose that this approach enhancing workforce opportunities vis-a-vis retention exposes participants to non-medical factors such as health insurance that support overall wellness. Such insights can also provide useful guideposts and techniques on how to maximize employment retention to the benefit of a young woman’s chosen career path and the employers’ goals and objectives.

MATERIALS AND METHODS

Ascend program description

Ascend, a three month program under the auspices of a medical school located in the southwestern part of the United States, connected post high school completion inner city adolescents and young adult women (aged 18 to 24 years), to job training and career readiness resources with an objective of participant entry into stable employment in the healthcare field (17). Two case managers along with a behavioral therapist provided access to personal medical care, coaching and educational resources to youth on health, wellness, family planning, financial literacy, and relationship management. The training sessions provided a health career overview, job training opportunities, and financial and logistical assistance in community college enrollment. Workshops and events to build job readiness behaviors, networking, and life skills were offered regularly in collaboration with the sponsoring medical school and its Humans Resources department. A local foundation provided a need-based stipend to assist with the cost of tuition, books, transportation and other required items. Most clients also utilized a clinic affiliated with the job program as their medical home and benefited from free primary health care, including birth control and social work services. Youth were defined as high-risk or underserved based on their neighborhood high unemployment rates, documented risk behaviors and health disparities.

Subjects

The Institutional Review Board of the affiliated medical school reviewed and approved the evaluation protocol. Thirty- seven young women enrolled in the Ascend for health profession job training via the clinic portal. Of this group, 37% were African American and 55% Hispanic and 8% other with a mean age of 20.8. Most of the participants resided in inner city neighborhoods. Project exclusionary criteria included the inability to read or speak English and documented severe mental health issues.

Procedures

Two case managers using standardized intake forms obtained various demographic and behavioral information as part of the follow up process. Based on this information, like intake data, follow up assessments was compared to original scores and was generated from several specific data sets: Personal information including age, education and employment history. Data was collected on household information, which included members living with the participant, housing (apartment, home, rent or own) transportation, food, childcare and financial responsibilities. Relationship status, behavioral and parenting concerns, and legal issues or any adverse life experiences were also assessed. Health care needs both physical and mental care for themselves and family members was also queried.

Data analysis

The data analysis process used two methodologies to follow up on factors related to employment retention. First, for qualitative assessment, content analysis methodology [18] was used to provide internal validity and reliability to the retention. This technique also served as an exploratory tool to identify various influencers that predict employment retention among participants. Thematic analysis as defined by Boyatzis is a process-oriented methodology that organizes qualitative data and in this program barriers that impede employment recruitment and retention. Using this technique for qualitative information obtained through follow up forms and interviews, a member of the project team familiar with the community, who was not involved in client intake or discussion, independently summarized the themes that emerged subsequent to employment. Then the team discussed the subsequent factors related to Social Determinants of Health and reached a consensus on the factors impacting employment retention. Second, quantitative measures included the identification, types and participant issues and how they were associated with program retention.

RESULTS

 Four to six months following successful program completion, participant hiring status was queried. Of the 37 young women who completed the job-training program, 10 participants were successfully hired and were working. Of the group, 5 were employed in private medical services, 3 in medical school clinic support services, 1 in a pharmacy, and one in a hospital (Chart 1). The remaining 27 who completed the program were either actively looking for a job or waiting for completion of final qualifying activities such as a required remaining course, practicum or certification. This group remains connected to the program to track future hires post program. The 10 hired participants were asked to reflect on what barriers or social determinants of health were either positive or negative impacted their hire and employment retention.

Via content analysis of the responses of successfully the employed cohort, several circumstances that were initially found and mitigated during program enrollment still impacted retention. Thematic assessment found that even while employed, financial concerns involving food and housing costs was still the primary worry during employment. For some eviction was a chronic issue. Transportation was the second biggest issue as most participants still did not own a car and relied on public transportation which was often unreliable. Personal relationships ranked as the third roadblock to success and were prevalent. The Ascend therapist actively counseled individual participants to establish a personalized plan focusing on social and emotional techniques to manage these issues and behaviors associated any adverse child experiences. These results also suggest that even with a job, initial negative social determinants of health continued subsequent to program completion and employment hire.

DISCUSSION

Health disparities and their relationship to social determinants of health, especially employment, underscore the importance of developing strategies to support young women with less than a college degree to access and maintain living wage work. Our findings have also re-confirmed that the acquisition of a meaningful job may be one of the most significant factors in supporting their well-being. This assessment has attempted to answer several questions as to why there is a growing number of unemployed minority women who have attained a high school diploma and are unemployed. We first reviewed life or behavioral factors subsequent to hiring that influence job retention. Our findings, based on our combined thematic and quantified assessments along with selected theoretical models, suggest that factors which were addressed at program enrollment still were present and required monitoring subsequent to employment. The case managers along with the programs therapist frequently addressed the impact of initial negative social determinants of health which persisted subsequent to employment and required staff’s attention on a regular basis, such as housing and transportation instability which played a role in workplace reliability ultimately influencing job retention.

Based on the residual nature of documented negative social determinants of health, we found that continual program linkage and social support such as regular sessions or conversations with the case managers and/or behavioral therapist, even after employment, were mandatory. This was in part because the negative determinants were often complex and interrelated and the participants often lacked an access to a professional who could provide trusted and accurate information when contingency decisions were necessary. Our program therapist actively maintained a relationship with our program hires and was instrumental in addressing social support items especially those associated with adverse childhood experiences, family, parenting and interpersonal relationships.

Finally, we affirmatively posit that job training related programs, when linked to a medical home, can effectively modulate risk components that affect job retention. Several facts support this finding. Easy access to primary care in a medical home at no cost to the participant is useful. This portal also can provide needed vaccines, work related examinations and information to a variety of risk reduction questions. For this cohort of adolescent and adult underserved young women, the receipt of effective contraception especially the Long Acting Reversible Contraceptive devises at no cost provides a strong risk reduction strategy to workforce termination because of an unintended pregnancy. Associated sexually transmitted infections which unfortunately are increasing in prevalence in this population can also be addressed and treated in their medical home discretely and in a timely manner. Expedited partner treatment for the young women was also available in their medical home.

 Even with these value-added components, subsequent to program completion, several obstacles to hiring and related job retention became apparent. Because the project was focused on training for allied health professions, placement strategies often reached out to medical institutions. Even though many of our young women had completed required course works and related practicums along with the pre-requisite professional certifications, entry level employment required, in some cases, 2 years of previous experience. This was especially true for individuals who completed their training in phlebotomy and was a contributory factor for some of the 27 program completers who had not yet been hired. The case managers and recruiters, in some instances, developed a work around whereby applicants were hired by the institution for non-technical jobs but with the ability to move into those professions after a probationary period. These institutions did try to accommodate some of the applicants and waive barriers related to the presence of a non- violent misdemeanor on their application. This was facilitated, in part, by the understanding that the case managers and therapists continued their relationship with the client after program completion. Advancing these workplace accommodations in the future is important and subsequent dissemination of this approach can be facilitated both through conversations with human resources leadership and continued promotion via professional writing and presentations.

However, several limitations in our assessment exist which limit generalizability and should be mentioned. We acknowledge that our sample of hired and subsequently retained participants was small and non-randomized. In addition, although clients were at 150% of the federal poverty level or below, because of small numbers we were not able to make any comparisons by race. However, our data allowed us to identify up to 4 persistent conditions across all races that job retention. In addition, most of the social determinants of health discussed were not measured to assess health impacts but their cumulative presence in the participants’ lives. Moreover, this assessment did not have an intervention and control group. Nevertheless, many social determinants described – particularly related to financial security– represent persuasive and sometimes urgent evidence of the health impacts of social determinants. From a pragmatic point of view, one can make the case that employment is a enhances wellbeing, a useful component of an employee. In addition, our findings may suggest future investigations to monitor how initiatives of this type can influence employment and its influence on endemic poverty. We also recognize, given our sample was exclusively female, that programs perhaps should develop different strategies to encourage males to enroll in these ancillary but well-paying professions. We also can conclude that the practical application of adverse life experiences related to Adverse Childhood Experiences and Social Determinants of Health have relevancy to the employment of this population. Our data suggest that we can effectively provide individual support based on the participants’ identified risk level via their medical home to enhance their employability. Such insights provide useful guideposts on how to initially integrate and sustain at risk youth in productive jobs. This work also encourages future research on how to maintain the participation of minority youth in programs that will help their transition to sustainable wages and upward career mobility. Finally, the authors acknowledge that the results are generated from a sample of underserved adolescent and young adult women and the findings may not be relevant or germane to their male counterparts. Nevertheless, our initial efforts can provide guidance on steps that will assist scaling-up these work force interventions for implementation at the regional and state level. Such an approach can also be useful to more comprehensively understand the economic impact of enhancing employment for this cohort of underserved women. We also hope that our findings provide a pragmatic link between workforce development and widespread implementation of social determinants-targeted interventions.

Acknowledgements: Funding for this project was provided in part by JP Morgan Chase, The McGovern Foundation and The Madison Foundation.

REFERENCES

1. Braveman, P. & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129: 19-31.
2. Alegría, M., NeMoyer, A., Falgas, I.,  Wang,Y., & Alvarez, K.(2019). Social Determinants of mental health: Where we are and where we need to go. Current Psychiatry Reports; 20(11): 95.
3. Wang, E., Glazer, K.B., Howell, E.A., & Janevic, T.M. (2020). Social Determinants of pregnancy-related mortality and morbidity in the United States A systematic review. Vol. 135, No. 4. Obstetrics and Gynecology.
4. Thompson, R., Calica, R.H., Flaherty, E.G. et. al. Trajectories of Adverse Childhood experiences and self-reported health at age 18. (2015). Academy of Pediatrics. 15(5): 503–509.
5. Merrick M.T., Ford D.C., Ports K.A., et. al. (2019). Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morbidity and Mortality Weekly Reports; 68: 999-1005.
6. Flaherty E.G., Thompson R., Dubowitz H., Harvey E.M., English D.J., Proctor L.J., et. al. (2013). Adverse childhood experiences and child health in early adolescence. JAMA Pediatrics; 16: 622–29. [PubMed: 23645114]. 
7. Brown M.L. Integrative approaches to stress, anxiety and resilience. (2019). Pediatric Annuals. Jun 1; 48(6): e226-e230.
8. Earvolino-Ramirez, M. Resilience: a concept analysis. (2007) Nursing Forum.  Apr- Jun; 42(2): 73-82.
9. Windle, M. l. & Windle, R.C. (2012). Early onset problem behaviors and alcohol, tobacco, and other Substance use disorders in young adulthood. Drug Alcohol Dependency. February 1; 121(1-2): 152–158.
10. Connor, K.M. & Davidson, J.R. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). (2003). Depression and Anxiety. 18(2): 76-82.
11. Brown M.L. Integrative Approaches to Stress, Anxiety, and Resilience. (2019). Pediatric Annuals. Jun 1; 48(6): e226-e23.
12. Dubowitz, H., Thompson, R., Proctor, L., Metzger,, R.,  Black, M .M.,  English, D., Pool, G. Magder, L. Adversity, maltreatment, and resilience in young children.  American Academy of Pediatrics, Apr; 16(3): 233-239.
13. Ahonen, E.Q., Fujishiro, K., Cunningham T., & Flynn, M. (2018). Work as an inclusive part of population health inequities research and prevention. American Journal of Public Health, 108: 306-311. 
14. Burgard, S.A. & Lin, K.Y. (2013). Bad jobs bad health. How work and working conditions contribute to health disparities. American Behavioral Scientist, 57(8): 1105-1127.  
15. Epstein, J.A., Botvin, G.J., Griffin, K.W., & Diaz, T. (2001) Protective factors buffer effects of risk factors on alcohol use among inner city youth. Journal of Child and Adolescent Substance Abuse, 1: 77-90.
16. Thornton R.L.J., Greiner A., Fichtenberg, C.M., Feingold, B.J., Ellen J.M., & Jennings, J.M. Achieving a healthy zoning policy in Baltimore: Results of a health impact assessment of the transform Baltimore zoning code rewrite. (2013). Public Health Reports. 128(Supplement 3):87–103. [PubMed: 24179284]
17. Smith, P.B., Van Horn, A., Hatter R., & King J. (2021). Preparing opportunity youth for employment: identifying and reducing factors that deter job readiness and success. North American Journal of Psychology, March, 2021 ISSN 1527-7143 Vol. 23, No. 1. 
18. Boyatzis, R. E. (1998).  Transforming qualitative information: Thematic analysis and code        development.  Thousand Oaks, CA: Sage Publications.

PEER REVIEW

Not commissioned. Externally peer reviewed.

1. Braveman, P. & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129: 19-31.
2. Alegría, M., NeMoyer, A., Falgas, I.,  Wang,Y., & Alvarez, K.(2019). Social Determinants of mental health: Where we are and where we need to go. Current Psychiatry Reports; 20(11): 95.
3. Wang, E., Glazer, K.B., Howell, E.A., & Janevic, T.M. (2020). Social Determinants of pregnancy-related mortality and morbidity in the United States A systematic review. Vol. 135, No. 4. Obstetrics and Gynecology.
4. Thompson, R., Calica, R.H., Flaherty, E.G. et. al. Trajectories of Adverse Childhood experiences and self-reported health at age 18. (2015). Academy of Pediatrics. 15(5): 503–509.
5. Merrick M.T., Ford D.C., Ports K.A., et. al. (2019). Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morbidity and Mortality Weekly Reports; 68: 999-1005.
6. Flaherty E.G., Thompson R., Dubowitz H., Harvey E.M., English D.J., Proctor L.J., et. al. (2013). Adverse childhood experiences and child health in early adolescence. JAMA Pediatrics; 16: 622–29. [PubMed: 23645114]. 
7. Brown M.L. Integrative approaches to stress, anxiety and resilience. (2019). Pediatric Annuals. Jun 1; 48(6): e226-e230.
8. Earvolino-Ramirez, M. Resilience: a concept analysis. (2007) Nursing Forum.  Apr- Jun; 42(2): 73-82.
9. Windle, M. l. & Windle, R.C. (2012). Early onset problem behaviors and alcohol, tobacco, and other Substance use disorders in young adulthood. Drug Alcohol Dependency. February 1; 121(1-2): 152–158.
10. Connor, K.M. & Davidson, J.R. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). (2003). Depression and Anxiety. 18(2): 76-82.
11. Brown M.L. Integrative Approaches to Stress, Anxiety, and Resilience. (2019). Pediatric Annuals. Jun 1; 48(6): e226-e23.
12. Dubowitz, H., Thompson, R., Proctor, L., Metzger,, R.,  Black, M .M.,  English, D., Pool, G. Magder, L. Adversity, maltreatment, and resilience in young children.  American Academy of Pediatrics, Apr; 16(3): 233-239.
13. Ahonen, E.Q., Fujishiro, K., Cunningham T., & Flynn, M. (2018). Work as an inclusive part of population health inequities research and prevention. American Journal of Public Health, 108: 306-311. 
14. Burgard, S.A. & Lin, K.Y. (2013). Bad jobs bad health. How work and working conditions contribute to health disparities. American Behavioral Scientist, 57(8): 1105-1127.  
15. Epstein, J.A., Botvin, G.J., Griffin, K.W., & Diaz, T. (2001) Protective factors buffer effects of risk factors on alcohol use among inner city youth. Journal of Child and Adolescent Substance Abuse, 1: 77-90.
16. Thornton R.L.J., Greiner A., Fichtenberg, C.M., Feingold, B.J., Ellen J.M., & Jennings, J.M. Achieving a healthy zoning policy in Baltimore: Results of a health impact assessment of the transform Baltimore zoning code rewrite. (2013). Public Health Reports. 128(Supplement 3):87–103. [PubMed: 24179284]
17. Smith, P.B., Van Horn, A., Hatter R., & King J. (2021). Preparing opportunity youth for employment: identifying and reducing factors that deter job readiness and success. North American Journal of Psychology, March, 2021 ISSN 1527-7143 Vol. 23, No. 1. 
18. Boyatzis, R. E. (1998).  Transforming qualitative information: Thematic analysis and code        development.  Thousand Oaks, CA: Sage Publications.