J Occup Rehabil DOI 10.1007/s10926-014-9503-z

Factors Related to Employers’ Intent to Hire, Retain and Accommodate Cancer Survivors: The Singapore Perspective Angela Ka Ying Mak • Shirley S. Ho Hyo Jung Kim



Ó Springer Science+Business Media New York 2014

Abstract Purpose Despite the growing importance of cancer and return-to-work issues in occupational rehabilitation literature in the last decade, academic discussion is largely limited to survivors’ perspectives and some exploratory studies from the employer side. This paper applies two classic theoretical models—Theory of Planned Behavior and Social Cognitive Theory—and key measures from previous studies to identify explicit relationships that explain employer factors to hire and retain cancer survivors. Methods Data were collected from online surveys with senior management executives and senior human resource specialists from various organizations in Singapore, with a total of 145 responses. The 72-item survey instrument included a series of independent variables: (1) Attitudes toward cancer and cancer survivors; (2) Employers’ efficacy; (3) Perceived moral obligation; (4) Employers’ experience; (5) Outcome expectations; (6) Employment situation; (7) Social norms; and (8) Incentives, and dependent variables: (a) Employers’ intention to hire cancer survivors; and (b) Employers’ intention to retain cancer survivors. Results Regression analyses showed that the top three factors related to employers’ intention to retain cancer survivors are perceived moral obligations (b = .39, p \ .001), followed by attitudes toward cancer (b = .25, p \ .01), and employment situation (b = .17, p \ .05). Employers’ efficacy was associated with intention to hire (b = .22, p \ .05), coupled with attitude

toward cancer survivors (b = .22, p \ .01). The findings also indicated the important role of existing relationship between an employer and an employee when it comes to retaining cancer survivors and government incentives for hiring cancer survivors in the workforce. Conclusions The present study provided an avenue to implement the proposed model—a potential study framework for the management of cancer survivors at work. Findings revealed that different messages should be tailored to employers toward hiring and retention issues and provided useful guidelines for employer education materials. Keywords Cancer survivor  Employers  Hiring  Retaining  Return to work

Introduction Employment and return to work makes up a large part of social reintegration, and this is essential for a cancer survivor as it brings back a sense of normalcy or control [1]. Furthermore, it can aid the ‘‘transition from being a patient to a survivor’’ [2]. As cancer survivors experience obstacles such as physical and psychosocial post-treatment side effects [3–5], there are other practical aspects of employment for cancer survivors, such as helping them to reduce their financial burden, increase their quality of life, and hold onto their personal health insurance [6].

A. K. Y. Mak (&) School of Media Film and Journalism, Monash University, Berwick Campus Building 903, Melbourne, VIC 3806, Australia e-mail: [email protected]

Past Studies on Employers and Organizational Perspectives

S. S. Ho  H. J. Kim Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore, Singapore

Amir et al. [7] summarized employers’ three major areas of concern regarding the employment of people who are returning to work after chronic health conditions including

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cancer through focus group studies with human resource (HR) managers and hiring project managers of national and international companies: (1) The productivity level of the individual/the ability to meet the company’s performance standards; (2) The knowledge and understanding of how to hire and retain qualified individuals with chronic health conditions and how to approach such employment situations; and (3) External help and support to provide accommodations and adjustments for individuals at the workplace. In particular, the attitude and mindset of the employers as well as the existing relationships cancer survivors have with their employers and colleagues are major factors in determining if a cancer survivor returns to work [7]. A follow-up employer survey by the researchers with the Midwestern HR and line managers in the US indicated that employers’ knowledge of American Disabilities Act, job accommodations and inclusion of disabilities in the company’s diversity plan were the most important factors in predicting their commitment to hiring people with disabilities [8]. In addition, a study with the British line managers from various sizes of organizations identified five positive and negative attitudes and concerns toward employing and/or retaining cancer survivors: (1) fearful attitudes toward cancer survivors, (2) supportive attitudes, (3) the anticipated burden from line-managers, (4) sustaining normality and (5) financial benefit issues [9]. Results also showed that a variety of return-to-work services were provided and the respondents regarded employee related factors, such as employee attitudes and emotional functioning, as a key to a successful return to work for cancer survivors.

Toward an Integrated Employer Behavioral Model The above studies from the ‘‘demand’’ side contribute to some understanding toward employers, in relation to work models [10–12] in which key factors such as work environment, individual factors, effects of cancer and treatments, and interventions and rehabilitation programs promoting return to work and employment were identified. Due to a need to identify more explicit relationships that explain employer factors that can influence work outcomes, the present study investigated the application of the Theory of Planned Behavior (TPB) [13] and the Social Cognitive Theory (SCT) [14] to help delineate specific relationships at the organizational level. Both theories complement each other as the TPB gives a microscopic view while the SCT provides a macroscopic one, thereby offering a comprehensive perspective on the decision making process of hiring and retaining cancer survivors and examine the interaction among personal, environmental, and behavioral factors of employers.

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Personal 1. Attitudes - toward cancer - toward cancer survivors 2. Efficacy 3. Perceived moral obligation 4. Experience with cancer survivors 5. Outcome expectation

Behavioral 1. Intention to hire cancer survivors 2. Intention to retain cancer survivors

Environmental 1. Employment situation 2. Social norms 3. Incentives

Fig. 1 Proposed integrative model. Adapted from [14, 15]

Ajzen’s TPB is used because it explains the decision making process of individuals by looking at intentions and behaviors, which arises from the attitude toward behavior and subjective norms, with the added dimension of perceived behavioral control [13]. The TPB is suited to examine the hiring and retaining decision-making processes from employers. Bandura’s SCT looks at how acquisition of behavioral patterns is related to the interaction of personal, environmental, and behavioral factors [14]. It also demonstrates how behavior is affected by socio-cultural factors that work through human cognition. In sum, this study tests an integrative model that describes a set of relationships regarding employers’ intention to hire and retain cancer survivors, devoid of government policies that can influence employer-employee interactions related to cancer and work. A proposed model explaining employers’ intention is summarized in Fig. 1.

Methodology Singapore citizens make up about 5.28 million of the population, and are distinguished by a multicultural ethnic group comprising the Chinese (77 %), Malay (14 %), Indian (8 %), and Eurasian (1 %) [15]. Another 30 % of the country’s entire population is made up of expatriates and foreigner workers. Despite being a small country, Singapore is ranked sixth out of 191 countries on overall health system performance by World Health Organization [16]. A market-based economy, Singapore is also ranked by the World Bank for four consecutive years as being the best place in the world to do business [17]. To date, none of the work-related initiatives from government-industry collaborations focused on cancer survivors [18]. In addition, Roche [19] argues that while the government may provide the impetus for fair employment practices

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and social responsibility, Singapore’s strong paternalistic style of governance may partly breed inertia among local organizations. Compounding on this socio-cultural barrier, cancer survivors are not protected by discriminatory act in Singapore [18] and cancer is not even listed as one of the common chronic diseases [20], and neither is it included in the definition of people with disabilities (PWDs) [21]. Also, unwritten HR policies are not uncommon in Singapore, which lead to some unintended social consequences and work challenges to cancer survivors [22]. The current study employed a quantitative survey using regression analysis to examine intention to hire or retain cancer survivors by employers in Singapore. Based on the central themes identified in the previous qualitative interviews using the integrative model (Fig. 1) as well as key findings from the past studies, a 72-item survey that contained measures of our independent and dependent variables, was completed. The survey was approved by the human subjects board from a local university. Participants and Procedure Respondents of our online web survey comprised of employers and senior management from various organizations and industries. The choice of using an online survey to obtain the information was based on the fact that our target respondents hold senior or managerial positions in their respective organizations, and may not be readily available for a personal interview and perhaps reduce turnaround time [23, 24]. The survey was hosted on a local university’s Qualtrics portal. A pre-test of the web survey was conducted with the participation of five HR executives and five employees with managerial/directorial appointments. This was done to ensure that the questions were understood and well structured, and that there were no technical glitches during the period of the survey. Given that cancer is perceived as a ‘‘taboo’’ and sensitive topic in the Singapore society, respondents were assured of confidentiality and anonymity prior to taking the web survey. The online survey was launched in 2012 for 3 weeks. With assistance from a national HR training center, we distributed the questionnaire to various companies and organizations in their mailing list. Measures Independent Variables Attitude Toward Cancer Six items, modified from previous studies [13] and our in-depth interviews, were used to compute this measure on a semantic scale of 1–5. This

measure consists of ‘‘Scary (1)—Not scary (5)’’, ‘‘Avoidable (1)—Unavoidable (5)’’, ‘‘Uncommon (1)—Common (5)’’, ‘‘Fatal (1)—Curable (5)’’, ‘‘Distant (1)—Real (5)’’, and ‘‘Contagious (1)—Not contagious (5)’’. These six items were averaged into a composite index (M = 3.44, SD = .65, Cronbach’s alpha = .49). Attitude Toward Cancer Survivors This is a six-item measure on a 5-point semantic scale with 1 = ‘‘Less than healthy people’’, 3 = ‘‘Same as healthy people’’, and 5 = ‘‘More than healthy people’’. The items were adapted and modified from previous studies [8, 13] and our in-depth interviews. These six items include: ‘‘Determined’’, ‘‘Motivated’’, ‘‘Forgetful’’, ‘‘Capability’’, ‘‘Adaptability’’, and ‘‘Sociable’’. These six items were averaged into a composite index (M = 3.23, SD = .52, Cronbach’s alpha = .76). Employer’s Efficacy A four-item measure scale, modified from Ajzen [13] was established from the ranges of 1 to 5, with 1 = ‘‘Strongly Disagree’’ and 5 = ‘‘Strongly Agree’’. The four items include (a) ‘‘I am confident that my organization can afford to employ a cancer survivor’’; (b) ‘‘I believe that I will be able to help an employee who is a cancer survivor adapt to the workplace’’; (c) ‘‘My organization has a supportive work culture which is helpful when I hire a cancer survivor’’; and (d) ‘‘I am confident that I am able to handle prospective employment situations should I hire a cancer survivor’’. These four items were averaged into a composite measure (M = 3.20, SD = .97), yielding a Cronbach’s alpha of .91. Perceived Moral Obligation Four items, modified from Gorsuch and Ortberg [25], were used to measure perceived moral obligation. On a scale of 1–5, with 1 = ‘‘Strongly Disagree’’ and 5 = ‘‘Strongly Agree,’’ the items are (a) ‘‘I would feel morally obliged to help if I meet a job applicant who is a cancer survivor’’; (b) ‘‘I would feel morally obliged to help if my employee is a cancer survivor’’; (c) ‘‘I find it wrong to reject an applicant because he/she is cancer survivor’’; and (d) ‘‘I find it wrong to ask an employee, who is diagnosed with cancer, to leave the organization’’. These four items were averaged to form a composite index (M = 3.78, SD = .97, Cronbach’s alpha = .84). Employer’s Experience Two items were used to compute this measure. 79 % of the respondents answered ‘‘No’’ and 21 % answered ‘‘Yes’’ for the first item ‘‘Have you encountered a job applicant who is a cancer survivor?’’. For the second item ‘‘I have employed a cancer survivor before’’, 72 % answered ‘‘No’’ and 29 % answered ‘‘Yes’’. The two items were summed up to create a continuous index (M = 4.12, SD = .59, KR-20 = .59).

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Outcome Expectation Three items, derived from our indepth interviews, were used for the measure of outcome expectation, using a scale of 1 to 5, with 1 = ‘‘Strongly Agree’’ and 5 = ‘‘Strongly Disagree’’. This measure was reverse-coded in order to generate a positive outcome expectation. The measure includes the following items: (a) ‘‘A cancer survivor’s ability to work will always be poorer than that of a healthy person’’; (b) ‘‘Cancer survivors will be a burden to my organization’’; and (c) ‘‘I anticipate problems in the organization should I hire a cancer survivor’’. A composite index was computed by averaging these three items (M = 3.41, SD = .71, Cronbach’s alpha = .65). Employment Situation The employment situation measure, modified from Bandura [14] and Chan et al. [8], comprises of nine items using a scale of 1 to 5, with 1 = ‘‘Not at all concerned’’ and 5 = ‘‘Very concerned’’. The measure is made up of (a) ‘‘Potential opinions of other employees’’; (b) ‘‘Financial resources of organization’’; (c) ‘‘Position cancer survivor is applying for’’; (d) ‘‘Urgency of employing candidate for the job’’; (e) ‘‘Other overriding qualities of the cancer survivor (e.g. experience, knowledge)’’; (f) ‘‘Type of cancer when diagnosed’’; (g) ‘‘Stage of cancer when diagnosed’’; (h) ‘‘Current state of health of the cancer survivor’’; and (i) ‘‘Cost of insurance coverage for the cancer survivor’’. These items were averaged to form a composite index (M = 3.64, SD = .69, Cronbach’s alpha = .82).

averaging these four items (M = 3.99, SD = .95, Cronbach’s alpha = .88). Dependent Variables Intention to Hire and Accommodate This measure, derived from Chan et al. [8] and our in-depth interviews, was computed using seven item on a scale of 1 to 5 with 1 = ‘‘Not at all likely’’ and 5 = ‘‘Very likely’’. These seven items are: (a) ‘‘Hiring a cancer survivor’’; (b) ‘‘Allow for probation/internship period’’; (c) ‘‘Start out with less work’’; (d) ‘‘Flexible work scheme (e.g. part-time, flexible working hours)’’; (e) ‘‘Work from home’’; (f) ‘‘Projectbased assignments’’; and (g) ‘‘No special arrangements’’. The seven items were averaged to create a composite index (M = 3.14, SD = .84), with the Cronbach’s alpha value of .78. Intention to Retain and Accommodate On a scale of 1 to 5, with 1 = ‘‘Not at all likely’’ and 5 = ‘‘Very likely’’, a two item measure was made up of ‘‘Retaining an existing employee who is a cancer survivor’’ and ‘‘Retaining and making special arrangements for an existing employee who is a cancer survivor’’. The two items, derived from Chan et al. [8] and our in-depth interviews, were averaged to create a composite index (M = 4.06, SD = .91, Cronbach’s alpha = .89). Analytical Approach

Social Norms Six items, modified from Bandura [14], were measured on a scale of 1 to 5, with 1 = ‘‘Strongly Disagree’’ and 5 = ‘‘Strongly Agree’’. The items are: (a) ‘‘My organization will be viewed positively by consumers’’; (b) ‘‘My organization will be viewed positively by other industry partners’’; (c) ‘‘My organization will be viewed positively by the government’’; (d) ‘‘My organization will be viewed positively by current employees’’; (e) ‘‘My organization will be viewed positively by potential employees’’; and (f) ‘‘I believe that hiring a cancer survivor is an important part of corporate social responsibility for my organization’’. These items were averaged to create a composite index (M = 3.40, SD = .89), and the reliability analysis gave a Cronbach’s alpha of .93.

We ran two separate multiple regression analyses using SPSS18 to analyze how our independent variables predict our dependent variables—(a) intention to hire and accommodate and (b) intention to retain and accommodate. In each of the multiple regression analyses, the following independent variables were entered simultaneously into the models: efficacy, attitude toward cancer survivors, perceived moral obligation, outcome expectation, attitude toward cancer, situation, social norms, incentives, and experience. Standardardized beta coefficients with p \ .05 in the regression models are significant results.

Incentives A 5-point scale, derived from Chan et al. [8] and our in-depth interviews, was used for this measure, with 1 = ‘‘Not at all’’ and 5 = ‘‘A lot’’ on the Likert scale. The four items measured include (a) ‘‘Direct tax rebate’’; (b) ‘‘Direct subsidies for insurance’’; (c) ‘‘Government grants’’; and (d) ‘‘Useful information on managing cancer survivors at work’’. The composite index was created by

We gathered a total of 145 responses. Table 1 shows respondents’ characteristics. Respondents were involved in a range of employment sectors including: manufacturing; wholesale and retail services; construction; information and communications; business services; hotels and restaurants; transport and storage; and financial services. Others (25 %) include a compilation of businesses

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Results

J Occup Rehabil Table 1 Sample characteristics Variable

N (%)

Table 2 Multiple regression of intention to hire and accommodate cancer survivors Variables

b

t

p

Efficacy

.22

2.01

\.05

Position Human resource

10 (7)

Attitude toward cancer survivors

.22

2.41

\.05

Incentives

.12

1.31

[.05

Perceived moral obligation

.13

1.28

[.05

40 (28)

Outcome expectation

.12

1.20

[.05

21–60

19 (13)

Attitude toward cancer

.09

1.03

[.05

61–100

12 (9)

101 and above

51 (35)

Situation Social norms

.05 .04

.54 .45

[.05 [.05

Missing

23 (15)

Experience

.01

.14

[.05

Management Others

115 (79) 20 (14)

Company size \20

Business/industry Manufacturing

23 (16)

Construction

15 (10)

Wholesale and retail

16 (11)

Information and communications

12 (8)

Business services

22 (15)

Others

35 (25)

Did not indicate

22 (15)

Employer’s Efficacy

ß = .22, p < .05

Intention to Hire

Encountered cancer survivor before

ß = .22, p < .01

Yes

30 (21)

No

115 (79)

Attitude toward cancer survivors

Employed cancer survivor before Yes

42 (29)

No

103 (71)

including travel agencies, trading services, property consultancy, chemical-based industries, and security firms and 15 % of the respondents did not indicate.

Employer Factors Related to Hiring and Retaining a Cancer Survivor Regression Model Predicting Employers’ Intention to Hire and Accommodate Table 2 and Fig. 2 indicate the results of the multiple regression model predicting employers’ intention to hire and accommodate cancer survivors. The overall model explained a significant amount of variance in hiring intention, F(9, 105) = 6.18, p \ .001, R2 = .29. The strongest predictor of intention was employer’s efficacy, followed by attitude toward cancer survivors. Regarding self-efficacy, employers believed they can effectively help a cancer survivor adapt to the workplace, though financial cost of employing a cancer survivor was also a concern. The other independent variables had no significant association with intention to hire and accommodate cancer survivors.

Fig. 2 Impact of employer’s efficacy and attitude toward cancer survivors on the intention to hire and accommodate

Regression Model Predicting Employers’ Intention to Retain and Accommodate Table 3 and Fig. 3 indicate the results of the multiple regression model predicting intention to retain and accommodate cancer survivors. The overall model explained a significant amount of variance in intention, F(9, 107) = 9.40, p \ .001, R2 = .40. The strongest predictor of intention was employer’s moral obligation, followed by Table 3 Multiple regression of intention to retain and accommodate cancer survivors Variables

b

t

p

Perceived moral obligation

.39

4.15

\.001

Attitude toward cancer

.25

3.10

\.01

Situation

.17

1.99

\.05

Outcome expectation

.14

1.56

[.05

Social norms

.08

1.03

[.05

Efficacy

.07

.72

[.05

Incentives

.07

.78

[.05

Attitude toward cancer survivors

.01

.01

[.05

-.04

-.49

[.05

Experience

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ß = .17, p < .05

Employment situation

ß = .39, p < .001 Intention to Retain

Perceived Moral Obligation

ß = .25, p < .01 Attitude toward cancer

Fig. 3 Impact of employment situation, perceived moral obligation, and attitude toward cancer on the intention to retain and accommodate

attitude toward cancer, and employment situation. As for moral obligation, respondents reported that they felt a moral obligation to ask cancer survivors to stay irrespective of the need for workplace accommodation. Employers report that it is simply not acceptable practice to ask an employee who has been diagnosed with cancer to leave the organization and feel that the least they can do is to let them remain at work. The rest of the independent variables were not significantly associated with the outcome variable.

Discussion The present study identified key factors related to employer hiring and retention of cancer survivors. The strongest factor related to the intention to hire was employer’s efficacy, followed by attitude toward cancer survivors. The strongest factor related to intention to retain was perceived moral obligations, followed by attitude toward cancer, and employment situation. Responding to Amir et al. [7] call for more research to be done from the demand-side of employment, our study provided some explicit relationships that explain different employment decision processes. Marrying health communication and organizational behavior, the integrative model explores how various personal and environmental factors combine to affect the behavior of hiring or retaining cancer survivors. Findings from the integrative model suggested that attitudes and subjective norms such as efficacy and attitude toward cancer survivors in Ajzen’s TPB [13] are crucial to employers in hiring cancer survivors, which is consistent to the previous demand-side studies [7, 8]. In contrast, moral values and environmental factors such as perceived moral obligations and employment situation are top criteria in retaining cancer survivors. This provides a new perspective of understanding the employers’ perspectives beyond the

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personal level. Not only does the integrative model provide a more comprehensive understanding of human behavioral processes, it also sheds light on recognizing the influence of the various factors that would result in a conclusive behavior. The difference between the factors influencing employers’ intention to hire and intention to retain might be due to an existing relationship employers have with current employees who are cancer survivors [7]. The importance of this preexisting relationship between employer and employee was also highlighted by Bouknight et al. [26] in their study examining the effect of employers’ attitude toward women following breast cancer treatment and decision to return to work. While this pre-existing relationship is related to work outcomes, it is important to consider that the belief that the employer can handle and accommodate cancer survivors, i.e. employer efficacy, is related to a hiring decision more so than their perceived moral obligation. The pre-existing relationship with the employee might also partly explain why employment situation was related to the intention to retain, but not to the intention to hire. Employers who are familiar with the employee who is a cancer survivor may have a better grasp of the employment situation [7], and will be able to make a more informed decision as to whether he/she will be able to reintegrate into the organization. An employer’s attitude toward cancer survivors was not related to the decision to retain. However, attitude toward cancer survivors is significantly related to the intention to hire [9]. Employers, in the process of hiring a cancer survivor for the first time, will have a limited frame of reference and their attitudes toward cancer survivors might have a direct and/or indirect behavioral impact on their hiring decisions.

Implications As Singapore at this current stage does not have any workplace policies for cancer survivors, the findings of this paper are not influenced by workplace policies. The case background offers a unique opportunity for this study as an example of investigating these factors primarily from the employers’ standpoints. For keeping existing employees who are stricken by cancer, perceived moral obligation (i.e., social responsibility) should be heavily highlighted, with specific guidelines on how to handle cancer survivors in the current workplace employment situations (i.e., adjustment and accommodation). The basic knowledge of cancer and its effects should also be included. For considering cancer survivors as new-hires, increasing employers’ efficacy and their knowledge on understanding

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cancer survivors at work through vocational rehabilitation interventions are key to success.

Limitations and Conclusion The sensitive nature of hiring policies may also have affected the willingness of organizations to participate. The use of a survey created for this study in the absence of preexisting psychometric development can be considered a limitation, however, the questions did go through cognitive testing in a pilot set of participants and the questions were all face valid which might have been sufficient for this analysis. We cannot rule out the influence of social desirability in querying about attitudes regarding prosocial behavior, however, findings are consistent with other studies [7–9, 26, 27] and do point to areas for further exploration and potential intervention. It should be also acknowledged that this study analyzed a single survey conducted in Singapore, limiting the generalizability of our findings. More diverse contexts involving other countries should be further examined to see if the key factors found in this study would remain in other contexts with different cultures from Singapore, and if not, how so. Finally, current models of cancer and work have not broken down the organizational element that is often included. The present study is an attempt to further specify this area. Acknowledgments We thank Colleen Chua, Joyce Leong, Rosalinda Yapit, Philemon Foo, Lim Pei Yi and Irwin Tan for their invaluable contributions to the study. This work was supported via the Singapore Cancer Society grant 2010. Conflict of interest The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

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Factors related to employers' intent to hire, retain and accommodate cancer survivors: the Singapore perspective.

Despite the growing importance of cancer and return-to-work issues in occupational rehabilitation literature in the last decade, academic discussion i...
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