Original Articles
Outcomes of an employment support program in psychiatric day care collaborate with the public employment service: a single-arm preliminary study
2022 年 4 巻 1 号 論文ID: 2021-0009-OA
詳細
2022 年 4 巻 1 号 論文ID: 2021-0009-OA
Objective: To evaluate the employment outcomes and changes in cognitive and social functioning of people with mental disorders using an employment support program in collaboration with psychiatric day care and the public employment service. Methods: This was a prospective, open-label, single-arm preliminary study. The employment support program was conducted 6 hours at a time, five times per week for 3 months. Participants’ employment rates within 6 months after the program ended and competitive employment in supported employment service 1 year later were calculated. The brief assessment of cognition in schizophrenia (BACS), Global Assessment of Functioning (GAF), and Life Assessment Scale for the Mentally Ill (LASMI) were measured before and after the program. Results: Forty-one (74.5%) of the 55 participants worked within 6 months of completing the program. Of the 30 employees who had been working for 1 year, 23 (76.7%) had settled in the workplace, with an average of over 80 monthly working hours and more than ＄660 monthly income. BACS Composite score (p<0.01, r=0.68), GAF (p<0.01, r=0.47), LASMI daily living (p<0.01, r=0.44), interpersonal relations (p<0.01, r=0.55), Work (p<0.01, r=0.81), endurance and stability (p<0.01, r=0.65), and self-recognition (p<0.01, r=0.78) improved significantly after the program. Conclusion: Our study suggests that a high employment rate can be obtained by employment support in which psychiatric day care and the public employment service cooperate.
Vocational rehabilitation improves verbal, social, and quality of life (QOL) outcomes for people with mental disorders1) and has been linked to good outcomes in terms of competitive employment, employment length, and wages. In this population, employment can reduce defeatist beliefs and accelerate the recovery process2,3). Furthermore, the synergistic benefits of cognitive remediation training in employment support have been demonstrated by a large body of research4,5,6,7,8,9,10).
Employment support for people with mental disorders is an important topic. In Japan, most psychiatric rehabilitation professionals are affiliated with medical institutions. However, although these professionals may offer such patients training to prepare them for the labor market, they do not necessarily coordinate their services with the local vocational centers and employment support offices who help them find work. In recognition of this weakness, the Ministry of Health, Labour and Welfare (MHLW) has advocated a policy of coordination between medical and vocational support centers to further stimulate employment in this population. In 2018, it allowed private companies to include mental disorders when calculating for the statutory employment rate for people with disabilities. Such systemic reforms have occurred alongside annual growth in the numbers of new jobseekers and hires with disabilities, which reached historically high levels in 2018 according to MHLW statistics11). The rise in jobseekers requiring vocational support, such as those with mental or developmental disorders, has been particularly conspicuous.
Numerous studies have reported the employment rate figures for people with mental disorders in Japan. According to MHLW statistics, 47.4% of new applicants with mental illness who sought work in 2018 at the Public Employment Security Office (public employment service) were successful in doing so (48,040/101,333)12). Ito et al.13) reported an employments rate of 63.8% for patients with severe mental illness who participated in a supported employment intervention in which cognitive remediation was integrated. In comparison, Ikebuchi et al.14) found that about 15% of patients with schizophrenia had been hired within 6 months of completing a cognitive rehabilitation intervention. Likewise, vocational support has been widely studied outside of Japan, especially in terms of the effectiveness of Individual Placement and Support (IPS) for individuals with severe mental illness. In a systematic review of 15 randomized controlled trials investigating the effectiveness of IPS-based employment assistance, Bond, Drake, and Becker found that IPS recipients became gainfully employed at markedly higher rates than the corresponding control groups (mean: 58.9% vs. 23.2%, median: 63.6% vs. 26.0%)15).
In 2015, the public employment service started an employment support initiative to partner with medical centers; as of 2018, sponsored programs have been operating at one to two locations in each prefecture. This project is intended to provide vocational support in tandem with healthcare by setting up partnerships between these facilities and local public employment services to assist the sharing of information about users and employers. In practice, however, these efforts lack a unified methodology and strategy, as the specifics of the relationship and assistance provided are devolved to individual centers or branches.
Tikumaso Mental Hospital entered into such a partnership agreement with the public employment service in 2016, and the two have continued to closely coordinate their efforts ever since. Employment support has been incorporated as part of our psychiatric day care program, with a public employment service employee assigned to the facility to handle operations and provide individual consultations to users as part of the staff16). This kind of partnership between the public employment service and a medical institution is truly unique, having never been previously reported in Japan.
Hence, our objective in this study was to investigate employment rates among people with mental disorders who completed this employment support program, along with associated changes in cognitive, social, and global functioning.
The program in question operates at an outpatient psychiatric day care in the rehabilitation division of Tikumaso Mental Hospital, a psychiatric hospital located in the provincial city of Ueda in Nagano Prefecture. The day care’s staff consists of one psychiatrist, one registered nurse, one occupational therapist, one psychiatric social worker, one clinical psychologist, and two assistants. In total, 93 people are registered at the day care center (64 males, 29 females), and the average daily attendance is 28. Users in their 50s make up a plurality (24.7%), followed by those in their 40s (23.7%), 30s (22.6%), 20s (21.5%), 60s (6.5%), and teens (1.1%). The breakdown of users’ diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is as follows: schizophrenia spectrum and other psychotic disorder, 57.0%; neurodevelopmental disorders, 15.1%; depressive disorders, 9.7%; bipolar and related disorders, 6.5%; anxiety disorders, 5.4%; and other, 6.5%. They had been visiting the day care center for 39.0 (standard deviation [SD], 68.1) months on average (median, 11.0 months), but with high variation among individuals (range, 1 month to 28 years)17). Day care services are available 5 days per week, from Monday to Friday; users varied widely in their usage frequency (range: 1–5 visits/week). The day care center is normally open for 6 hours per day, from 0900 to 1500. The normal program for psychiatric day care at Tikumaso Mental Hospital consists of a combination of occupational therapy, sports, and psychological education (readers should note that the employment support program under discussion here is separate and distinct from this program).
The public employment serviceThe Public Employment Security Office (called “Hellowork”) is an administrative agency established by the Japanese government (specifically, the MHLW), with the aim of guaranteeing stable employment opportunities to citizens. The organization offers consultations and guidance to users looking to find or change jobs and refers them to employers that match their wishes and suitability. All branches are connected online, and specialized units are available for people with disabilities, elderly people, and other social groups. There are 14 branches within Nagano Prefecture; The Public Employment Security Office Ueda — the one partnered with Tikumaso Mental Hospital — serves 200,000 local residents and is located a mere 2 km from the hospital.
Employment support programOur program — entitled Employment Support Program in Cooperation with the public employment service (ESPCP) — was intended for day care users with mental disorders seeking employment. Table 1 compares the characteristics of ESPCP with those of regular employment support before the start of ESPCP. ESPCP was provided in a closed group of 10 people; they ran for 3 months, 5 days per week, for 6 hours per day, while their activities were managed by the day care’s interdisciplinary care team (led by the occupational therapist) and the public employment service officials. Program components included psychoeducation, social and business skills training, metacognitive training (MCT), physical fitness (exercise), computer training, and preparatory workplace training. At the start of the program, the staff members of an employment and life support center for people with disabilities in the Ueda area were added to the support team. Regular employment support does not include groups and programs such as psychoeducation, physical fitness (exercise), and craft activities. Psychoeducation was provided for over 18 sessions based on the Illness Management and Recovery (IMR) model. IMR is a standardized psychosocial intervention; it was developed to provide people with severe mental illnesses with methods to more effectively cope with their symptoms and stress and achieve their personal recovery goals18). A toolkit of IMR has been developed together with fidelity checklists for the practitioners19,20);the Japanese version was published by the Japanese Association of Psychiatric Rehabilitation in 200921). Sessions on different topics in the curriculum were led by different team members: “Recovery” by the occupational therapist, “Health Management” by the registered nurse, “Medication Management” by the pharmacist, “Crisis Planning” by the clinical psychologist, and “Social Resources” by the psychiatric social worker and the public employment service staff.
| ESPCP | Regular employment support | |
|---|---|---|
| Program | Closed group program of 10 users managed by day care and the public employment service included psychoeducation, social and business skills training, metacognitive training, physical fitness (exercise), computer training, and preparatory workplace training | Normal day care programs (No groups) included psychoeducation, physical fitness (exercise) and craft activities |
| Schedule | Running for 3 months, 5 days per week, for 6 hours per day | Rehabilitation period and frequency will be decided individually |
| Participant | Outpatients aged 18 to 65 years | Outpatients over 18 years of age |
| Support team | Coordination between day care, the public employment service and employment, and life support center for people with disabilities | Day care staff |
| Collaboration | “Inclusive” in which users receive parallel support from the support team | “Relay race” in which users are passed from medical center to the public employment service, and then to a local vocational center and/or employment support office |
ESPCP, Employment Support Program in Cooperation with the public employment service.
Social and business skills training was designed to teach users how to communicate appropriately in the workplace, including topics such as greetings, small talk, and interview techniques. Users were instructed through lectures and role-playing by the occupational therapist, the public employment service staff, and representatives of potential employers. MCT is a specialized psychoeducation program developed by Moritz and colleagues to help patients with schizophrenia to correct cognitive biases22,23,24). This component consisted of a total of eight group sessions, led by the occupational therapist, involving one or more of the following modules: “Attribution,” “Jumping to conclusions,” “Changing beliefs,” “Theory of mind,” “Memory,” and “Mood and self-esteem.” Physical fitness was supported by outdoor walks, aerobic exercise (e.g., volleyball, softball, and tennis), and twice-weekly strength training. Computer training taught participants how to prepare the resumés and curriculum vitae they would need in job hunting, as well as certain kinds of documents using the Microsoft Office suite (Word, Excel, and PowerPoint).
Workplace training gave participants the opportunity to practice with an employer of interest vetted by the public employment service and local support staff. Once or more during the program, each user practiced a light load of duties on site for 1 to 2 weeks, with periodic visits from the support staff to guide and encourage them to continue. Meetings were held after the program was over to allow participants to share their workplace experiences. Once a week during ESPCP, each participant was provided with recruitment information by the public employment service staff and was interviewed separately to confirm their intentions. Graduates were also provided with job search assistance as needed after completing the program. At the time of the recruitment interview, the support team members accompanied the employees and explained to them their performance on assessments (traits). The hospital staff had limitations and difficulties in obtaining information from the workplace; hence, we clarified the role of the staff in the workplace. The employers decide to hire users, as well as managers to adjust the work environment according to the user’s disability characteristics, colleagues to work together considering the user’s disability characteristics, and occupational health staff to exchange information with the hospital and the public employment service staff. In addition, we adopted assertive outreach and provided continuous employment support in the form of workplace visits, phone calls, and care conferences attended by the support team and a representative of their employer. Self-monitoring worksheets incorporated in psychoeducation were utilized after users secured their employment to support self-management. Similar assistance was provided to participants who wished to find general employment (i.e., positions not designated for persons with disabilities), with team members accompanying them to potential workplaces and interviews. Participants whose job searches were successful were followed up after 1 year after being hired. ESPCP Collaboration is “inclusive”, with users receiving parallel support from the support team. However, collaboration of regular employment support is characterized as a “relay race”, in which users are passed from medical center to the public employment service and then to a local vocational center or employment support office.
Study designThis was a prospective, open-label, single-arm preliminary study evaluating competitive employment in supported employment service. Our primary outcome was the competitive employment rate of ESPCP completed within 6 months from the end of the program. Competitive employment was defined as being successfully hired for a job that is open to applicants from the general public, involving at least 5 hours of work per week, and paying at least the minimum wage as codified in Japanese law6). Successful hires were followed up for 12 months after being hired to assess their employment outcomes, including continuous employment rate, total number of weeks and number of hours worked, total wages, and hours worked per month. Secondary outcomes were changes in cognitive, social, and global functioning during the program, which are evaluated as respective differences in assessment scores at the end of the program compared with baseline. Cognitive functioning was evaluated using the Brief Assessment of Cognition in Schizophrenia (BACS)25). The BACS assesses multiple aspects in cognitive functioning of schizophrenia that includes six measures: verbal memory, working memory, motor speed, verbal fluency, attention, and executive functioning. Each of the six measures was standardized by creating z-scores, whereby the mean scores of the healthy participants were set to zero, and the standard deviations were set to one. Global functioning was assessed using the Global Assessment of Functioning (GAF), an integrated measure of social, occupational, and psychological functioning rated on a numerical scale from 1–10026). Social functioning was evaluated using the Life Assessment Scale for the Mentally Ill (LASMI)27). Respondents answer questions in five domains using a five-point Likert scale: “Daily living,” “Interpersonal relations,” “Work,” “Endurance and stability,” and “Self-recognition.” Higher scores indicate more severe dysfunction.
ParticipantsUsers of the Tikumaso Mental Hospital psychiatric day care were eligible to join if they were between the ages of 18 and 65, were motivated to work, and consented to use disability employment services and participate in the ESPCP program. No DSM-5 diagnosis was considered exclusionary17).
Statistical analysisThe competitive employment rate in the 6 months after the end of ESPCP was calculated separately for all participants and for those with severe mental illness (SMI; defined here as having schizophrenia or depression) for comparison with previously reported figures. Wage, which is an employment outcome, was collected as Japanese yen (JPY) and then converted to United States dollars (USD) using the exchange rate for the reference date, which was March 31, 2020 (USD 1.00 equal to JPY 107.68). Participants’ pre- and post-ESPCP scores on the BACS, GAF, and LASMI, as well as antipsychotic doses (chlorpromazine equivalent) were compared using the Wilcoxon signed-rank test. Significance was set at p<0.05; equivalent correlations of r=0.10, 0.03, and 0.05 were considered to indicate small, medium, and large effect sizes, respectively.
A total of 55 days care users enrolled in the ESPCP program (36 males, 19 females, mean age, 35.0; SD, 10.8 years) and completed it. Of them, 42 (76.4%) had a diagnosis of depression or schizophrenia (SMI group). Most participants had never married (n=42, 76.4%) and had a competitive work history of at least 12 months (n=41, 74.5%). In addition, their antipsychotic dosages were statistically comparable before and after ESPCP (Table 2).
| Age, years, mean (SD) | 35.0 | (10.8) | |
| Sex | Male, n (%) | 36 | (65.5) |
| Female, n (%) | 19 | (34.5) | |
| Diagnosis | Schizophrenia, n (%) | 21 | (38.2) |
| Schizoaffective disorder, n (%) | 2 | (3.6) | |
| Depressive disorders, n (%) | 19 | (34.5) | |
| ASD/ADHD, n (%) | 11 | (20.0) | |
| Others, n (%) | 2 | (3.6) | |
| Ill period | Years, mean (SD) | 7.2 | (6.3) |
| Delivery of disability certificate | Yes, n (%) | 50 | (91.0) |
| Marital status | Never married, n (%) | 42 | (76.4) |
| Separated or divorced, n (%) | 8 | (14.5) | |
| Education; High school, or more, n (%) | 55 | (100) | |
| Number of hospitalizations, mean (SD) | 0.7 | (1.1) | |
| Competitive work history (12 months or more), n (%) | 41 | (74.5) | |
| Competitive work in past 6 months, n (%) | 8 | (14.5) | |
| Antipsychotic medication (CP), mean (SD) | |||
| Pre- ESPCP, mg/day | 439.2 | (374.4) | |
| Post- ESPCP, mg/day | 420.9 | (347.4) |
ADHD, attention deficit-hyperactivity disorder; ASD, autism spectrum disorder; CP, chlorpromazine; ESPCP, Employment Support Program in Cooperation with the public employment service; SD, standard deviation.
Table 3 shows the competitive employment rate of participants after ESPCP. Just under three-quarters (41/55, 74.5%) found a job within 6 months from the end of the program, with a slightly higher proportion for the SMI group (35/42, 83.3%). On average, graduates were hired 96.7 (SD, 51.9) days after completing the program. A plurality found jobs in the service industry, such as supermarkets and retailers (n=12, 21.8%), which involve responsibilities, such as stocking shelves and customer service. Fourteen participants did not find a job within 6 months of completing the ESPCP program: 11 of them continued to visit the day care, while 3 switched to welfare-related offices and services (employment transition support: n=2, continuous employment support: n=1). Feeling inadequately prepared for employment was a major reason cited (e.g., “I’m not confident enough” and “I’m late and absent a lot”).
| Competitive employment, n (%) | 41 | (74.6) | |
| ∙ Service industry | 12 | (21.8) | |
| ∙ Manufacturing | 9 | (16.4) | |
| ∙ Office work | 7 | (12.7) | |
| ∙ Cleaning industry | 5 | (9.1) | |
| ∙ Medical and welfare industry | 5 | (9.1) | |
| ∙ Others | 3 | (5.5) | |
| Continues psychiatric day care center, n (%) | 11 | (20.0) | |
| The Facility of Employment Support and Assistance, n (%) | 2 | (3.6) | |
| The Facility of Support for Continuous Employment, n (%) | 1 | (1.8) | |
ESPCP, Employment Support Program in Cooperation with the public employment service.
Table 4 shows employment-related outcomes for successful hires 1 year after their onboarding date. In total, 30 out of the 41 who had completed the ESPCP program, including 25 of the 35 in the SMI group, were followed up successfully 1 year after hiring. The 1-year continuous employment rates overall and for SMI graduates were 76.7% (23/30) and 80.0% (20/25), respectively. On average, members of both groups were working over 40 weeks and 1,000 hours during the 12-month follow-up period, earning over ＄660 in wages, and working 80 hours per month.
| Employment outcome | Total (n=30) | SMI (n=25) | ||
| Continuous employment after 1 year | n | (%) | N | (%) |
| No | 7 | (23.3) | 5 | (20.0) |
| Yes | 23 | (76.7) | 20 | (80.0) |
| mean | (SD) | mean | (SD) | |
| Total number of weeks | 42.8 | (16.9) | 44.4 | (15.3) |
| Total number of hours | 1007.1 | (522.0) | 1044.3 | (512.2) |
| Total wages, USD | 7975.0 | (4394.2) | 8276.6 | (4358.1) |
| Worked hours/month | 83.9 | (43.5) | 87.0 | (42.7) |
USD, United States dollars; SMI, severe mental illness.
Pre- and post-ESPCP assessment scores are shown in Table 5. Significant improvements were observed in the BACS composite score (p<0.01, r=0.68) and in five of its six domains: verbal memory (p<0.05, r=0.29), working memory (p<0.01, r=0.53), verbal fluency (p<0.01, r=0.35), attention (p<0.01, r=0.41), and executive functioning (p<0.01, r=0.55). GAF score significantly improved as well (p<0.01, r=0.47). Finally, significant improvements were observed in all LASMI domains: daily living (p<0.01, r=0.44), interpersonal relations (p<0.01, r=0.55), work (p<0.01, r=0.81), endurance and stability (p<0.01, r=0.65), and self-recognition (p<0.01, r=0.78).
| Measure | Pre (n=55) | Post (n=55) | p | Z | r | ||
|---|---|---|---|---|---|---|---|
| Mean | (SD) | Mean | (SD) | ||||
| BACS | |||||||
| Verbal memory | −0.85 | (1.18) | −0.67 | (1.10) | 0.03* | 2.13 | 0.29 |
| Working memory | −0.61 | (0.96) | −0.22 | (1.06) | 0.00** | 3.95 | 0.53 |
| Motor speed | −1.27 | (1.18) | −1.14 | (0.98) | 0.17 | 1.37 | 0.18 |
| Verbal fluency | −0.57 | (1.00) | −0.42 | (0.90) | 0.01** | 2.59 | 0.35 |
| Attention | −0.70 | (1.01) | −0.47 | (0.93) | 0.00** | 3.04 | 0.41 |
| Executive functioning | −0.34 | (1.06) | 0.24 | (0.87) | 0.00** | 4.11 | 0.55 |
| Composite score | −0.72 | (0.79) | −0.44 | (0.69) | 0.00** | 5.02 | 0.68 |
| GAF | |||||||
| GAF score | 68.55 | (6.16) | 70.09 | (5.26) | 0.00** | 3.52 | 0.47 |
| LASMI | |||||||
| Daily living | 6.15 | (5.46) | 5.44 | (5.14) | 0.00** | 3.30 | 0.44 |
| Interpersonal relations | 15.00 | (4.42) | 13.22 | (3.87) | 0.00** | 4.09 | 0.55 |
| Work | 16.98 | (4.62) | 12.38 | (4.49) | 0.00** | 6.02 | 0.81 |
| Endurance and stability | 4.36 | (1.41) | 3.45 | (1.28) | 0.00** | 4.78 | 0.65 |
| Self-recognition | 5.20 | (0.82) | 3.87 | (1.18) | 0.00** | 5.77 | 0.78 |
BACS, Brief Assessment of Cognition in Schizophrenia; ESPCP, Employment Support Program in Cooperation with the public employment service; GAF, Global Assessment of Functioning; LASMI, Life Assessment Scale for Mentally Ill; SD, standard deviation.
*p<0.01, **p<0.01
The ESPCP’s employment outcomes were superior to those in previously reported vocational rehabilitation studies. Our results show that the ESPCP program achieved high employment rates: 74.6% for all who completed the program, which is higher than the 47.4% reported MHLW figures to date, and 83.3% for those with severe mental illnesses, which is higher than the rates of the meta-analyses studies of IPS (70.4% [Campbell et al, 2011], 70.0% [Bond et al, 2012b])12,28,29). Moreover, a nationwide survey on the continuous employment of persons with disabilities in Japan conducted by the National Institute of Vocational Rehabilitation showed that the continuous employment rate of people with mental disabilities at 1 year after employment with a general company is 49.3%, which is lower than other disability areas, such as physical disabilities30). In comparison with conventional the public employment service services within the jurisdiction of Nagano Prefecture, the ESPCP’s employment rates are higher than any of that reported in the last decade (41–58%)31). Our results indicated that the continuous employment rate was 76.7% for ESPCP and 80.0% for SMI, which was higher than the previous reported retention rate (66%) in Japan32).
The ESPCP also showed better results than other employment support programs in terms of other employment outcomes. Regarding the total number of weeks, our result of 42.8 weeks was longer than the 20.53, 20.0, and 20.53 weeks reported in previous studies15,28,29). Regarding total number of hours worked, our result of 1,007.1 hours was longer than those in previous meta-analyses, which reported 417.6 and 284.3 hours15,29). However, the total number of hours worked was shorter than the 1,236 hours as reported by the MHLW33). Regarding total wages, our result (USD 7,975.0) was higher than the USD 3,704 found by Bond et al.29), but lower than the USD 13,950 reported in an MHLW report33). In hours per month, our result of 83.9 hours was higher than the 13.3 hours found as a result of a previous meta-analysis but was less than the 103 hours found by the MHLW29,33).
Assessment scores completed before and after ESPCP revealed markedly improved cognitive functioning (as rated by BACS) and global functioning (as measured by LASMI). These enhancements could have also increased their likelihood of employment. Studies have indicated there is no correlation between employment performance and the severity of psychiatric symptoms, and that cognitive and social functioning both influence employment performance34,35). Similarly, the benefits of incorporating cognitive remediation training into vocational support programs is supported by a long list of works4,5,6,7,8,9,10). The fact that ESPCP includes group work to cultivate attendees’ social and business skills, in addition to psychoeducation and MCT, likely helped in improving their cognitive and social functioning, which led to the high employment rates observed.
Our preliminary study had a number of limitations that have to be acknowledged. First, this project-based study was conducted at a single site, with a small sample size, and without a control group. Second, researchers were not blinded to participants’ identities during evaluation. Third is the possible selection bias of participants; those who could participate in the ESPCP might already be in a better condition at the beginning. Fourth, we did not control for “work identity” and “negative perceptions regarding mental disorders,” which have been reported in a previous meta-analysis as factors related to work in persons with mental disorders. Further research is warranted to replicate the effects of this program, including research using a multi-site randomized controlled trial with a larger sample size design. The optimal design for examining the effects of ESPCP would have been a two-study comparison — between ESPCP and placebo and ESPCP and IPS — even though a much larger sample size would be required. Fifth, there was also some degree of incomplete outcomes data in the study, as well as the lack of cognitive, social, and global functioning ratings at follow-up. Follow-up assessments also are needed to analyze the factors that influence continuous employment rates. Finally, the method of comparing employment rates with past reports does not employ meta-analysis. Nevertheless, the ESPCP demonstrated higher rates of employment than other supported employment programs.
Our results provide preliminary support for the effects of providing the ESPCP, which is an employment support program involving a strong partnership and coordination between a psychiatric day care center and the public employment service. This demonstrates that the ESPCP can help participants find and continue employment at high rates. These findings encourage the promotion of the ESPCP for participants with mental illnesses and have the potential to improve vocational rehabilitation in Japan. Future studies are warranted to examine the effects of ESPCP.
The authors wish to thank the participants and staffs. This research is supported by the Japanese Ministry of Health, Labour and Welfare budget for promoting employment of persons with disabilities.
None declared.
This study was approved by the ethics review committee of the Medical Corporation Yuaikai (accession number: 20200401).
Written informed consent was obtained from all participants.
All authors conceived the study concept and study design. KK and SH carried out the program and performed compilation and synthesis of the data. TS carried out statistical analyses. KE and MK supervised the research project. All authors participated in interpretation of the results and writing of the report and approved the final version.
