Disparities in Vocational Rehabilitation Services and - Southern ...

J Head Trauma Rehabil Vol. 22, No. 2, pp. 85–94 c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright

Disparities in Vocational Rehabilitation Services and Outcomes for Hispanic Clients With Traumatic Brain Injury: Do They Exist? Elizabeth da Silva Cardoso, PhD; Maria G. Romero; Fong Chan; Alo Dutta; Maryam Rahimi [AQ1]

Objective: Examine disparities in vocational rehabilitation (VR) services for Hispanic clients with traumatic brain injury. Design: Logistic regression analysis of secondary data. Participants: Five thousand eight hundred thirtyone European American and Hispanic clients. Main Outcome Measures: Type of services and employment status. Results: European Americans were 1.27 times more likely to obtain employment than were Hispanics. Hispanics with work disincentives had lower odds of returning to work and had more unmet basic needs (eg, food, shelter, and transportation) that need to be addressed in the rehabilitation process. Job placement and on-the-job support services were found to significantly improve employment outcomes. However, on-the-job support services were more likely to be provided to European Americans than to Hispanics. Keywords:

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ESEARCH has demonstrated that employment has a significant impact on improving the quality of life of individuals with traumatic brain injury (TBI).1,2 Vocational rehabilitation (VR) services have always been an integral part of TBI rehabilitation. With return-towork as the central goal, an important benefit of aggressive VR service programming within the overall operation of TBI treatment program is its capacity to provide direction, focus, and meaning to other therapies or services. In this sense, VR is best regarded as a “pull factor” (ie, the therapy that provides meaning, focus, and direction) and, as such, is distinguished from other “push factor” therapies (ie, those services from which the client will hopefully become independent).3 In spite of a persistently strong desire to work, persons with TBI continue to experience employment rates

[AQ2]

From the Department of Educational Foundations and Counseling, Hunter College, City University of New York (Dr Cardoso); the Department of Rehabilitation Psychology and Special Education, University of Wisconsin at Madison (Mss Romero and Chan); the Department of Rehabilitation and Disability Studies, Southern University, Baton Rouge, La (Ms Dutta); and the Department of Rehabilitation Studies, University of Maryland Eastern Shore (Ms Rahimi). This study was supported in part by funding from the Rehabilitation Research Institute for Underrepresented Populations (National Institute on Disability and Rehabilitation Research grant #H133A031705) at Southern University, Baton Rouge, La. Corresponding author: Elizabeth da Silva Cardoso, PhD, Department of Educational Foundations and Counseling, Hunter College, City University of New York, 695 Park Ave, W1017, New York, NY 10021 (e-mail: ecardoso@ hunter.cuny.edu).

that hover around 30% to 40%. This, in turn, leads to a decrease in personal resources and corresponding increase in dependence on public assistance.4 Importantly, some of the characteristics of unemployed persons with TBI include race/ethnicity, low education, transportation problems, and history of substance abuse.5 Since the state-federal rehabilitation services program serves the largest number of people with disabilities in the country and closes about 600,000 cases per year, state VR agencies continue to be a viable vocational programming option for people with TBI. Several studies have investigated the effect of state VR services on employment outcomes for individuals with TBI. For example, Johnstone et al6 found that active participation in VR was a stronger predictor of job success than were medical and psychological information, personal characteristics, or skill level. Successful employment was positively predicted by the provision of VR services such as counseling and guidance, college, and job placement services,7 supported employment services,8 and assistive technology.9 Wehman et al10 reported that in 1993 only 3094 individuals with TBI were served by state VR agencies, compared to 15,304 in 2001 and approximately 54,000 between 1993 and 2001. However, the majority of these clients with TBI were men (67.2%) and predominantly White (83.0%). According to Miller,11 Hispanics are rapidly becoming the largest ethnic minority group in the United States, representing about 14.9% of the population. The incidence of TBI in the United States is 200 per 85

[AQ3]

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100,000, whereas the incidence among Hispanics is 262 per 100,000. Most Hispanics with TBI are single males in their mid-thirties who have sustained their injuries via automobile accidents, falls, or violence.12 Wilson and Senices13 indicated that these changing demographics could have significant implications for the state-federal rehabilitation services program. Specifically, because of overrepresentation in menial labor and hazardous occupations, people with disabilities from racial and minority backgrounds tend to have higher rates of work injury and disability than do European Americans.14 In addition, culture, language, and way of life have a significant influence on acquisition, reporting, and treatment of long-term disabilities. As a result, rehabilitation counselors (RCs) are now working with increasingly larger numbers of clients from racial and ethnic minority backgrounds. However, RCs are predominantly European Americans and may hold a different worldview than their ethnic and racial minority clients do. Wilson and Senices13 identified the following issues for Hispanic clients in VR: (a) White counselors may not be familiar with the Hispanic culture; (b) White counselors may lack the language skills and appropriate multicultural rehabilitation counseling competencies to work effectively with Hispanic consumers; and (c) these factors may affect the effectiveness of rehabilitation services and employment outcomes. Similar concerns about the detrimental effect of ethnic and racial bias against African Americans had been highlighted in the Rehabilitation Act Amendments of 1992: Patterns of inequitable treatment of minorities have been documented in all major junctures of the vocational rehabilitation process. As compared to European Americans, a larger percentage of African-American applicants to the vocational rehabilitation system is denied acceptance. Of applicants for service, a larger percentage of African-American cases is closed without being rehabilitated. Minorities are provided less training than their European American counterparts. Consistently, less money is spent on minorities than their European American counterparts.15(p4364)

Because of these changing demographic trends and the federal government’s concerns about racial bias in VR services, VR disparities research has become an important topical area in recent years. For example, Capella16 tested several logistic regression models using gender and race as predictors of eligibility rates and employment outcomes for VR clients. The results of the logistic regression analysis indicated that (a) acceptance for service rates favored European over African Americans after controlling for age and education; (b) employment outcomes favored European Americans over African Americans; and (c) quality of closures favored men over women. However, the primary focus of VR disparities studies has been on African Americans with

disabilities and not on other racial and ethnic minority groups. In addition, most studies did not focus on the effect of work disincentives and service patterns on employment outcomes. As mentioned, Hispanics with disabilities represent a growing disability population who increasingly will need state VR services. However, few research studies examine disparities of VR services and outcomes for Hispanics with disabilities, especially Hispanics with TBI. The purpose of this study was to examine Hispanic VR service disparities in terms of demographics, work disincentives, service patterns, and employment outcomes. Specifically, this study poses the following research questions: 1. Do competitive employment outcomes vary between European American and Hispanic clients with TBI? 2. How do the variables of demographics, work disincentives, and VR services affect competitive employment outcomes? 3. Do VR services exhibit any disparities between European American and Hispanic clients with TBI? METHODS Participants Data for this study were extracted from the Rehabilitation Service Administration Case Service Report (RSA911) data, which contain personal history, services, and employment outcome information on all clients receiving state vocational rehabilitation services in the United States. This large archival data set is furnished annually to RSA by state vocational rehabilitation agencies across the country and has been used to study racial bias in eligibility determination and employment outcomes of people with disabilities. In fiscal year (FY) 2005, 356,229 cases were closed either in status 26 (successful) or in status 28 (unsuccessful). Of these 356,229 closures, there were a total of 6888 TBI cases including 5394 in European Americans and 437 in Hispanics. VR clients coded as “White, non-Hispanic” were extracted from the RSA-911 database to represent European Americans, and clients coded as “Latino” or “Hispanic” were extracted from the same database to represent Hispanics. The demographic characteristics of the sample and case service information are presented in Table 1. Of the 5831 European American and Hispanic VR clients in this study, 3812 were men (65%) and 2019 were women (35%). Six hundred twenty-eight clients had cooccurring psychiatric disabilities (10%), and 161 (3%) had cooccurring alcohol and other drug abuse problems. Mean age of participants was 33.69 years (SD = 12.23). Four percent had completed special education, 21% had less than high school education, 41% had completed

VR Disparities

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Descriptive statistics related to demographic characteristics and case service variables for the clients with traumatic brain injury TABLE 1

n (%) Variable Demographic variables Age, M (SD) Gender Men Women Education Special education Less than high school Completed high school Postsecondary/associate College degree or higher Preservice Employment Status Employed Not employed Significant disabilities Yes No Cooccurring psychiatric disabilities Yes No Cooccurring substance abuse problems Yes No Work disincentives Yes No Case service variables, M (SD) Time to become eligible for service Time in service No. of services Case expenditures Assessment Yes No Diagnostics and treatment Yes No Counseling and guidance Yes No College or university training Yes No Occupational/vocational training Yes No On-the-job training Yes No Remedial training Yes No Job readiness training Yes No

White

Hispanic

Total

33.91 (12.28)

30.97 (11.18)

33.69 (12.23)

3515 (65%) 1879 (35%)

297 (68%) 140 (32%)

3,812 (65%) 2.019 (35%)

227 (4%) 1081 (20%) 2106 (39%) 1338 (25%) 642 (12%)

32 (7%) 159 (36%) 139 (32%) 76 (17%) 31 (7%)

259 (4%) 1,240 (21%) 2,245 (39%) 1,414 (24%) 673 (12%)

885 (16%) 4509 (84%)

47 (11%) 390 (89%)

932 (16%) 4899 (84%)

125 (2%) 5269 (98%)

17(4%) 420 (96%)

142 (2%) 5689 (98%)

584 (11%) 4810 (89%)

44 (10%) 393 (90%)

628 (11%) 5203 (89%)

154 (3%) 5240 (97%)

7 (2%) 430 (98%)

161 (3%) 5670 (97%)

2994 (56%) 2400 (44%)

254 (58%) 183 (42%)

3,248 (44%) 2,543 (56%)

1.54 (2.53) 30.54 (25.20) 4.37 (2.32) $4659 (8,097)

1.74 (2.35) 31.96 (25.94) 4.70 (2.42) $3897 (6,2967)

1.55 (2.52) 30.64 (25.25) 4.40 (2.33) 4601 (7.978)

4033 (75%) 1361 (25%)

314 (72%) 123 (28%)

4347 (75%) 1484 (25%)

2021 (38%) 3373 (62%)

200 (46%) 237 (54%)

2221 (38%) 3610 (62%)

3526 (65%) 1868 (35%)

281 (64%) 156 (36%)

3807 (65%) 2024 (35%)

882 (16%) 4512 (84%)

75 (17%) 362 (83%)

957 (16%) 4874 (84%)

707 (13%) 4687 (87%)

82 (19%) 355 (81%)

789 (14%) 5042 (86%)

272 (5%) 5122 (95%)

30 (7%) 407 (93%)

302 (5%) 5529 (95%)

126 (2%) 5268 (98%)

11 (3%) 426 (97%)

127 (2%) 5694 (98%)

734 (14%) 4660 (86%)

62 (14%) 375 (86%)

796 (14%) 5035 (86%) (Continues)

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Descriptive statistics related to demographic characteristics and case service variables for the clients with traumatic brain injury (Continued) TABLE 1

n (%) Variable Augmentative skills training Yes No Miscellaneous training Yes No Job search assistance Yes No Job placement assistance Yes No On-the-job supports Yes No Transportation services Yes No Maintenance Yes No Rehabilitation technology Yes No Technical assistance services Yes No Information and referral Yes No Other services Yes No

White

Hispanic

Total

264 (5%) 5130 (95%)

27 (6%) 410 (94%)

291 (5%) 5540 (95%)

727 (14%) 4467 (86%)

40 (9%) 387 (91%)

767 (13%) 5064 (87%)

1734 (32%) 3660 (68%)

143 (33%) 294 (67%)

1877 (32%) 3954 (68%)

2044 (38%) 3350 (62%)

151 (35%) 286 (65%)

2195 (38%) 3636 (62%)

1327 (25%) 4067 (75%)

82 (19%) 355 (81%)

1409 (24%) 4422 (76%)

1512 (28%) 3882 (72%)

170 (39%) 267 (61%)

1682 (29%) 4149 (71%)

725 (13%) 4669 (87%)

88 (20%) 349 (80%)

813 (14%) 5078 (86%)

480 (9%) 4914 (91%)

32 (7%) 405 (93%)

512 (9%) 5319 (91%)

162 (3%) 5232 (97%)

30 (7%) 407 (93%)

192 (3%) 5639 (97%)

865 (16%) 4529 (84%)

90 (21%) 347 (79%)

955 (16%) 4876 (84%)

1399 (26%) 3995 (74%)

138 (32%) 299 (68%)

1537 (26%) 4294 (74%)

∗ Reader

services, interpreter services, and attendant services were not reported because the number of clients with traumatic brain injury who received these services was minuscule.

high school, 39% had completed some post-secondary education or had an associate degree, and 12% had completed at least a college degree. The average time to become eligible for VR services was 1.55 months (SD = 2.52), whereas the average time between eligibility and case closure was 30.64 months (SD = 25.25). The average number of services received was 4.40 (SD = 2.33). The average case expenditure was $4601.46 (SD = $7977.88). On average, the European American clients in this study (M = 33.91, SD = 12.28) were found to be significantly older than Hispanic American clients (M = 30.97, SD = 11.18), t5829 = 4.84, P < .01. Hispanics were found to receive more services (M = 4.70, SD = 2.42) than did their European American counterparts (M = 4.37, SD = 2.32), t5829 = −2.78, P < .01. In general, both Hispanics (M = 31.96 months, SD = 25.94) and European Ameri-

cans (M = 30.54 months, SD = 25.20) spent about the same amount of time in the rehabilitation process. No difference in case expenditures was found between European Americans (M = 4659, SD = 8097) and Hispanics (M = 3897, SD = 6296), t5829 = 1.92, NS. Variables Outcome variable The outcome variable used was competitive employment. Competitive employment was defined in the RSA911 manual as employment in an integrated setting, self-employment, or employment in a state-managed Business Enterprise Program (BEP) that is performed on a full-time or part-time basis for which an individual is compensated at or above the minimum wage.

VR Disparities Unsuccessful outcome referred to clients who were not working after completing their planned VR program. Predictor variables Three sets of predictor variables were used for this study: demographic variables, work disincentive variables, and rehabilitation service variables. Demographic variables included gender (male or female), race (European American, African American, Hispanic/ Latino, Native American, or Asian American), age, education (special education, less than high school, high school graduate, associate degree, and college degree), severity of disability (significant vs not significant), preservice employment status (employed vs unemployed), and cooccurring disability (alcohol or other drug abuse [AODA], depression). Disincentive variables included the number of government benefits (Supplemental Security Income [SSI], Social Security Disability Insurance [SSDI], Temporary Assistance for Needy Families [TANF], general assistance, veterans’ disability benefits, workers’ compensation, and medical insurance not through employment). Vocational rehabilitation services variables included the following: Assessment—services provided and activities performed to determine an individual’s eligibility for VR services, to assign an individual to a priority category of a state VR agency that operates under an order of selection, and/or to determine the nature and scope of VR services to be included in the Individual Plan for Employment (IPE); included in this category were trial work experiences and extended evaluation. Diagnosis and treatment of impairments—surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category included diagnosis and treatment of mental and emotional disorders. Vocational rehabilitation counseling and guidance— discrete therapeutic counseling and guidance services necessary for an individual to achieve an employment outcome, including personal adjustment counseling; counseling that addresses medical, family, or social issues; vocational counseling; and any other form of counseling and guidance necessary for an individual with a disability to achieve an employment outcome; this service is distinct from the general counseling and guidance relationship that exists between the counselor and the individual during the entire rehabilitation process. College or university training—full-time or part-time academic training above the high school level that leads to a degree (associate, baccalaureate, graduate, or professional), a certificate, or other recognized educational credential; such training may be provided by a 4-year college or university, community college, junior college, or technical college.

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Occupational/vocational training—occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or certification. On-the-job training—training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same or a similar job upon successful completion; this category also includes apprenticeship training programs conducted or sponsored by an employer, a group of employers, or a joint apprenticeship committee representing both employers and a union. Basic academic remedial or literacy training—literacy training or training provided to remediate basic academic skills needed to function on the job in the competitive labor market. Job readiness training—training to prepare an individual for the world of work (eg, appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity). Disability-related, augmentative skills training—includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille, speech reading, sign language, and cognitive training/retraining. Miscellaneous training—any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma. Job search assistance—job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes, identifying appropriate job opportunities, developing interview skills, and making contacts with companies on behalf of the consumer. Job placement assistance—a referral to a specific job resulting in an interview, whether or not the individual obtained the job. On-the-job supports—support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention; such services include job coaching, follow-up and followalong, and job retention services. Transportation services—travel and related expenses necessary to enable an applicant or eligible individual to participate in a VR service; includes adequate training in the use of public transportation vehicles and systems. Maintenance—monetary support provided for expenses such as food, shelter, and clothing that are in excess of the normal expenses of the individual and that are necessitated by the individual’s participation in an assessment for determining eligibility for VR needs or that are incurred while an individual receives services under an IPE. www.headtraumarehab.com

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Rehabilitation technology—the systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes rehabilitation engineering services, assistive technology devices, and assistive technology services. Reader services—services for individuals who cannot read print because of blindness or other disability; includes reading aloud and transcribing printed information into Braille or sound recordings if requested by the individual; generally are offered to individuals who are blind or deaf-blind but may also be offered to individuals unable to read because of serious neurological disorders, specific learning disabilities, or other physical or mental impairments. Interpreter services—sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing, and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language interpretation. Personal attendant services—those personal services that an attendant performs for an individual with a disability, such as bathing, feeding, dressing, providing mobility and transportation, and so on. Technical assistance services—technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes. Information and referral services—services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the VR program. Other services—all other VR services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, initial stocks and supplies, and medical care for acute conditions arising during rehabilitation and constituting a barrier to the achievement of an employment outcome. Data analysis Data extracted from the RSA-911 data were analyzed using SPSS 13.0.17 Logistic regression analysis was used to examine the effect of work disincentives, demographic characteristics, and service patterns on rehabilitation outcomes. Odds ratios were computed to determine whether there was any disparity in the provision of VR services for Hispanic clients with TBI as compared to Whites.

RESULTS Employment outcomes between European American and Hispanic clients In FY 2005, 2961 European Americans with TBI (55%) were closed in status 26 (competitive employment) and 2443 (45%) were closed in status 28 (unemployment). In comparison, 214 Hispanics with TBI (49%) were closed in status 26 and 223 (51%) were closed in status 28. Odds ratios were computed to determine whether the differences in employment outcomes between European Americans and Hispanics were significant. In this analysis, “odds” refers to the ratio of the number of people having the good event (eg, employment) to the number not having the good event (eg, unemployment). The odds ratio is the ratio of the odds with condition A (European Americans) and that of the comparison condition, B (Hispanics). Values greater than 1 show that condition A is better than condition B, and if a 95% confidence interval is calculated, statistical significance is assumed if the interval does not include 1. The competitive employment rate for European Americans was 55% compared to 49% for Hispanics. The odds ratio of 1.27 was statistically significant (CI: 1.04 and 1.54; P < 0.05), indicating that European Americans were 1.27 times more likely to obtain competitive employment after receiving VR services than were Hispanics. The effect of demographic and case service variables on employment outcomes A logistic regression model was computed to analyze the main effects of demographic characteristics, work disincentives, and case service variables on the employment outcomes of VR clients. In addition, the interaction effects between race/ethnicity × work disincentives and race/ethnicity × VR services on outcomes were examined. The omnibus test for the logistic regression model was found to be statistically significant, χ 2 (53, N = 5831) = 750.68, P < .001. The Negelkerke R2 was computed to be 0.16, indicating that 16% of the variance in employment outcomes can be explained by the predictor variables. An R2 of 0.16 is considered a medium effect size in multiple regression analysis. The Hosmer and Lemeshow goodness-of-fit test was not significant, χ 2 (8, N = 5831) = 8.70, NS, indicating a good fit for the model. The first set of variables to be entered into the analysis was demographic variables, which included age, gender (with men as the reference category), race/ethnicity (with Hispanic as the reference category), education (with college graduates as the reference category), severity of disability (with severe disability as the reference category), cooccurring psychiatric disabilities and cooccurring AODA, work disincentives, and employment status

VR Disparities at application. In this step, gender was found to be a significant predictor (odds ratio = 1.16; 95% CI: 1.04– 1.30), indicating that men were 1.2 times more likely to be employed after receiving VR services than were women. Age was also found to be significant; the results indicated that clients aged between 35 and 54 years had a 13% reduction in odds of being employed than did clients aged between 16 and 34 years (odds ratio = 0.87; 95% CI: 0.77–0.97). Education was also found to be significant; results indicated that clients with less than a high school education or clients who were high school graduates had lower odds of being employed than did clients with a college education. The reduction in odds was 38% for high school dropouts (odds ratio = 0.62; 95% CI: 0.51–0.76), and 17% for high school graduates (odds ratio = 0.83; 95% CI: 0.69–0.99). People with work disincentives had a 37% reduction in odds of obtaining employment (odds ratio = 0.63; 95% CI: 0.56–0.70), and people with cooccurring AODA had a 35% reduction in odds of obtaining employment (odds ratio = 0.65; 95% CI: 0.47–0.89). In step 2, all VR services, with the exception of reader services, interpreter services, and attendant services, were entered as predictors. Reader, interpreter, and attendant services were excluded because the number of people receiving these services was minuscule. In this step, after controlling for the effect of demographic variables, 8 VR services were found to be statistically significant and they improved the odds of obtaining competitive employment. These services were substantial counseling (odds ratio = 1.24; 95% CI: 1.10–1.40), university training (odds ratio = 1.31; 95% CI: 1.12–1.54), vocational training (odds ratio = 1.29; 95% CI: 1.08–1.51), job search assistance (odds ratio = 1.25; 95% CI: 1.08–1.44), job placement assistance (odds ratio = 1.95; 95% CI: 1.71–2.23), on-the-job support (odds ratio = 2.18; 95% CI: 1.89–2.50), maintenance (odds ratio = 1.42; 95% CI: 1.20–1.68), and assistive technology (odds ratio = 1.27; 95% CI: 1.04–1.56). Most notably, clients who received job placement assistance and on-the-job supports were twice as likely to be successfully employed. In addition, transportation was found to be a significant risk indicator. Clients who needed transportation services during the rehabilitation process had a 22% reduction in odds of obtaining competitive employment (odds ratio = .78; 95% CI: 0.69–0.89). In the final step, the interaction terms between Hispanic and work disincentives and the interaction terms between Hispanic and VR services were entered. In this step, after controlling for the effect of demographic and VR service variables, there were 4 significant interaction effects. Three of these interaction terms could be considered risk factors; they were Hispanic × disincentives (odds ratio = 0.62; 95% CI: 0.32–0.99); Hispanic × comprehensive assessment (odds ratio = 0.47; 95%

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CI: 0.27– 0.81); and Hispanic × diagnostic/treatment (odds ratio = 0.60; 95% CI: 0.37–0.96). Hispanic clients who had work disincentives, who needed a comprehensive assessment to determine service needs, and who received physical or mental rehabilitation services had significantly lower odds of obtaining employment than did European American clients who received the same services and Hispanics and Whites who did not need these services. Conversely, Hispanic clients who received technical assistance services were 4.7 times more likely to become competitively employed (odds ratio = 4.70; 95% CI: 1.70–12.95). Disparities in essential services between European American and Hispanic clients The logistic regression analysis results indicated that substantial counseling, university training, vocational training, job search assistance, job placement assistance, on-the-job support, maintenance, and assistive technology services are central to the success of clients with TBI in vocational rehabilitation. Transportation service was identified as a risk factor and reduced the odds of successful rehabilitation outcomes. Simple odds ratios were computed to determine whether disparities in these services existed between Hispanic and European American clients. In this analysis, “odds” refers to the ratio of the number of people receiving the service to the number not receiving the service. This is the ratio of the odds with condition A (European Americans) and that of condition B (Hispanics). There was no significant difference between European American and Hispanic clients in their odds of receiving substantial counseling, university training, job search assistance, job placement assistance, and assistive technology services. Hispanic clients were 1.5 times more likely to receive vocational training than were European American clients (odds ratio = 1.53; 95% CI: 1.19–1.97); 1.6 times more likely to receive transportation services than were European American clients (odds ratio = 1.64; 95% CI: 1.34–1.20); and 1.5 times more likely to receive maintenance services than were European American clients (odds ratio = 1.62; 95% CI: 1.27–2.08). However, Hispanic clients had a 20% reduction in odds of receiving on-the-job support services than did European American clients (odds ratio = 0.71; 95% CI: 0.55–0.91), the most significant predictor of successful employment outcomes. DISCUSSION In this study, European American clients with TBI were found to have higher employment rates (55%) than Hispanic clients did (49%). However, in the logistic regression analysis, the Hispanic factor as a main effect on employment outcomes dissipated when taking into account other demographic factors such as preservice www.headtraumarehab.com

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employment status, severity of disability, and education. Importantly, work disincentives, cooccurring AODA, and lack of transportation were found to be significant risk factors to successful vocational rehabilitation. Substantial counseling, university training, vocational training, job search assistance, job placement assistance, onthe-job support, maintenance, and assistive technology services were found to be essential to successful outcomes. In general, there is no disparity between Hispanics and European Americans in many of these services. However, Hispanics were more likely to receive vocational training, transportation, and maintenance services than were European American clients. Conversely, European American clients were more likely to receive onthe-job support services, the most significant predictor of successful employment outcomes. Several variables interacted with the Hispanic status to affect employment outcomes. Work disincentives, comprehensive assessment, and diagnostic and treatment services were additional risk factors to employment that were specific to Hispanic clients. Conversely, technical assistance services were found to be a particularly significant predictor of successful employment outcomes for Hispanics. The negative effect of work disincentives on employment outcomes is well documented in the literature. In this study, work disincentives were found to have both a main effect and an interaction effect, suggesting that even though work disincentives affect both European American and Hispanic clients significantly, the effect was more profound for Hispanic clients. Legislative initiatives, such as the Ticket to Work and Work Incentives Improvement (TWWIIA) Act of 1999, have attempted to minimize the disincentives of disability benefit programs, and there is evidence to suggest that knowledge of these work incentive initiatives does impact a recipient’s employment decisions. Specifically, Hennessey18 found that if social security disability insurance recipients had knowledge of the trial work period and the extended period of benefits eligibility under new laws as well as assurance that they would continue receiving Medicare benefits, the effect of work disincentives would have dissipated. Therefore, rehabilitation professionals providing services to TBI clients, especially those who work with Hispanic clients with work disincentives, should become familiar with benefits counseling and financial planning/counseling services offered by the social security administration and state VR agencies. AODA was found to be a significant risk factor to successful employment outcomes. However, only 2.9% of the European American clients and 1.6% of Hispanic clients were identified as having cooccurring AODA problems in FY 2005. The low incidence of cooccurring AODA among European American and especially among Hispanic VR clients was unusual in

light of the fact that research has indicated that about 50% to 66% of the clients with TBI had a history of AODA. Ingraham et al19 found that rehabilitation counselors in state VR agencies were ill equipped to identify substance abuse problems in their clients with traumatic disabilities. Cardoso et al20 also reported that rehabilitation psychologists lack formal education and clinical training in substance abuse assessment and treatment, especially with clients from racial and ethnic minority backgrounds. Therefore, TBI rehabilitation professionals who utilize state VR agencies to provide employment services must work closely with VR counselors to help them better evaluate and treat cooccurring AODA problems in VR clients with TBI, especially those from racial and ethnic minority backgrounds. Administrators of state VR agencies should also consider providing in-service training on AODA assessment and treatment for their counselors who work with clients who have a high incidence of cooccurring AODA. Services related to job placement and job maintenance (eg, job search assistance, job placement assistance, onthe-job support) were found to be significant predictors of successful employment outcomes and job tenure. However, job placement and support services appear to be significantly underutilized in the vocational rehabilitation of TBI clients. In this study, job placement services were provided to only 38% of the clients with TBI (38% for European Americans and 35% for Hispanics), and on-the-job support service was provided to only 24% of the clients with TBI (25% for European Americans and 19% for Hispanics). On-the-job support is defined in the RSA-911 manual as support services (eg, job coaching, follow-up and follow-along, and job retention services) provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention. A VR client can be closed as successfully rehabilitated only after working successfully on the job for at least 90 days. Job coaching and the development of natural support in the workplace are important to successful employment of people with TBI. Because on-the-job support service was the most important predictor of employment success in this study, the fact that European American clients were more likely to receive on-the-job support services than were Hispanic clients would warrant further examination. Hispanic clients were found to receive more services than did European American clients. However, the case expenditure for European Americans was about $762 higher than for Hispanics. This amount is about 17% of the average case expenditure ($4601) for VR clients with TBI, suggesting that Hispanics were receiving more but lower-cost services. Specifically, it appears that Hispanics had more basic service needs. The higher need for basic services such as transportation and maintenance indicated that Hispanics faced more life crises

VR Disparities and barriers (food, shelter, clothing, transportation, etc) during the course of their rehabilitation. Hispanic clients who needed comprehensive assessment and diagnostic and treatment services had a higher risk of failure after receiving VR services. Assessment service is provided to determine an individual’s eligibility for VR services, to assign an individual to a priority category (eg, multiple functional limitations) of a state VR agency that operates under an order of selection, and/or to determine the nature and scope of VR services. A client requires comprehensive assessment when the rehabilitation counselor alone cannot determine the client’s eligibility or ascertain the client’s service needs. The need for assessment usually indicates a complex case. In the context of working with Hispanic clients with TBI, the difficulty can often be compounded by the interaction between disability and ethnicity/cultural factors. Rehabilitation counselors must be aware of these additional risk factors to work proactively with these higher risk Hispanic clients with TBI. Of all VR services, technical assistance service most significantly improved the employment outcomes of Hispanic clients with TBI. Technical assistance service is defined as consultation services provided to conduct market analyses, to develop business plans, and to provide resources to individuals in the pursuit of selfemployment, telecommuting, and small business operation outcomes. The almost 5-fold increase in employment outcomes suggested that self-employment and small business employment can be viable options for Hispanics with TBI, who are more likely to find support within the collectivism culture of their ethnic neighborhoods and communities. Therefore, although technical assistance was provided only to a small number of Hispanic clients, this employment alternative would warrant serious consideration by rehabilitation counselors in developing an IPE with Hispanic clients with TBI. In summary, the Hispanic status of VR clients does not seem to affect employment outcomes. It appears that both European American and Hispanic clients share similar vulnerability and immunity factors. Immunity factors include preservice employment status, higher educational level, and older age. Risk factors include work disincentives, AODA, and transportation problems. The risk of work disincentives is more profound for Hispanics than for European Americans. Additional risk factors for Hispanics include healthcare and mental health service needs. Job placement and support services were

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found to be the most important predictors of employment outcomes. These services were underutilized for both European American and Hispanic clients. However, European Americans had a higher chance of receiving on-the-job support services, the most significant predictor of employment, than did Hispanics. Conversely, Hispanics seemed to have higher basic service needs, including healthcare, mental health services, food, shelter, and transportation assistance. In terms of educational and training services, there was a higher propensity to provide vocational training to Hispanics and technical assistance for self-employment and small business development. It can be concluded that there is no major disparity in VR services for Hispanic clients with the exception of the provision of on-the-job support services. There is also no major disparity in employment outcomes after taking into consideration related factors such as preservice employment status, gender, age, and education. Hispanic clients do seem to have more risk factors than do European American clients. However, it appears that counselors in state VR agencies were making efforts to provide appropriate services for Hispanic clients with TBI. Limitations Data for this study were extracted from the RSA-911 database. A notable problem of the RSA-911 database relates to the way rehabilitation counselors record case service information at various stages in the rehabilitation process. For example, the information on type of disability is entered before an eligibility decision is made, and the wage and occupation data are entered when the case is closed. Thus, it is possible that if counselors did not consult the case file to verify which services were delivered and instead relied solely on memory, data could be incorrect. In addition, data input errors may accidentally be entered by the counselors. To overcome these potential errors, the Rehabilitation Services Administration developed 18 cross-checks to reduce the potential for error. However, even with these cross-checks in place, an unknown number of errors may still exist. Fortunately, these errors are assumed to be random and therefore should not result in systematic bias in the data. Finally, because this study used archival data and employs an ex-post-facto design, causality cannot be inferred.

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Title: Disparities in Vocational Rehabilitation Services and Outcomes for Hispanic Clients With Traumatic Brain Injury: Do They Exist? Authors: Elizabeth da Silva Cardoso, Maria G. Romero, Fong Chan, Alo Dutta, and Maryam Rahimi

Author Queries AQ1: Provide the highest academic degrees for Romero, Chan, Dutta, and Rahimi. AQ2: Check whether the affiliations are OK as typeset. Also check whether the social titles used for Romero and Chan (Mss), Dutta (Ms), and Rahimi (Ms) are OK. AQ3: Provide 3–5 keywords for your article. AQ4: Update the reference.