RRI Brief Rehabilitation Research Initiative The University of Texas-Pan American “Toward a Better Understanding of Strategies that Address Barriers to Access, Participation, and Success of Hispanic/Latino Consumers in Rehabilitation” by Fredrick E. Menz, Ph.D., University of Wisconsin-Stout Joan Reed, Ph.D., The University of Texas-Pan American Keith Wilson, Ph.D., Pennsylvania State University Linda Holloway, Ph.D., and Paul Leung, Ph.D., University of North Texas Thomas Shefcik M.S., The University of Texas-Pan American March 2006 Introduction The Rehabilitation Research Initiative (RRI) was an exploratory research capacity development project funded by the Rehabilitation Services Administration (RSA) to identify barriers and strategies to access, participation, and success for Hispanic/Latino individuals served through community rehabilitation programs (CRPs) and the state- federal vocational rehabilitation program (VR). This RRI Brief shares some key findings on barriers and introduces an expanded framework with which to better understand the complexity of barriers and how CRPs might effectively address them1. Methodology In this project, The University of Texas- Pan American (UTPA) and the University of North Texas (UNT) employed both qualitative and quantitative research methods with small national samples of vocational rehabilitation counselors, community rehabilitation program staff, and consumers from Hispanic/Latino backgrounds. Literature reviews identified seven primary barriers to services for minorities and underserved populations. Focus groups conducted with VR personnel, CRP staff, and eligible consumers verified the importance of seven barriers and provided additional understanding of their impact and some strategies to address them. Telephone interviews with CRP staff and web-based surveys with counselors provided estimates of the relative importance of the seven barriers, their impact for Hispanic/Latino and other minority individuals’ participation, and new knowledge about the interconnected barriers these individuals face2. Interconnected Barriers While nearly half (47%) of VR counselors reported that there are barriers to access rehabilitation services, virtually all VR counselors (N=163) and CRP staff (N=45) reported that important barriers to participation and success included all seven literature identified barriers: Transportation (88.3% of VR 1 An earlier University of North Texas CRP Brief presents a case for examining barriers to minority participation in CRP services and an overview of strategies identified in focus groups (Reed, 2004). 2 Please see the project monograph by Reed, Holloway, Shefcik, Leung, Menz, and Wilson (2005) for a full discussion of methods, samples, findings, and recommendations for research, policy, and practice. counselors report as important barrier); Lack of Knowledge of the Rehabilitation Process (77.9%); Cultural Mistrust (76.7%); Language (73%); Concept of Time (68.1%); Low Expectations for Job Placement (66.9%); and Technology (63.2%). 3 A discussion of the seven barriers and some practical strategies can also be found in Reed, Holloway, Leung, and Menz (2005). These are not exhaustive of the barriers Hispanic/Latino Americans face in participating and succeeding in culturally relevant vocational rehabilitation services, however. The large majority of VR counselors and CRP staff identified multiple and interconnected barriers that may be classified by their locus or origin (see Table 1). Our analyses further suggest that important barriers are interconnected as barrier sets (e.g., language and ethnicity and geographic location) for individuals and that some barriers are likely to be generic for people with disabilities and people who are poor (e.g., transportation, housing), while others are systemic and programmatic (e.g., referral policies, counselor decision making, where services are located). Yet others are societal and are present in the physical environment (e.g., community norms, employment outlook, accessible health care availability, low-cost housing); or have a strong cultural basis (e.g., stigma, expectations and prohibitions, concepts). And, others derive from the individual (e.g., status, needs, discretionary resources); or derive from family (e.g., expectations, supports). Our analyses also suggest that the relative importance among such sets may well be determined based upon perspective (e.g., consumer, community, counselor) and context in which the barrier(s) may play out differently (e.g., in a rural community without accessible transportation and only one CRP). An expanded framework to fully account for barriers to access, participation and success, we suggest, would consider the interaction of barrier locus or origin, context, perspective, and relative importance: • Locus or origin of barriers: Loci of barriers are within an individual, within their family and culture, present in social and physical environments, or originate within VR and CRP service systems. • Context in which barriers will be important: Contexts means that a barrier is general for people with disabilities, community specific, or culture specific. • Perspective on barrier importance: Perspectives are those of consumer, family, rehabilitation personnel, community, or those derived from cross-cultural studies. • Relative importance of barriers: Valuing of sets of barriers as important, occasionally important, or not important given interaction of locus, context and perspective. Complex Strategies Single strategies were rarely proposed to address any of the seven literature-identified barriers and there was no clear consensus on which strategies would work barrier-by-barrier across various communities and cultural groups3. Many suggested strategies emphasized core rehabilitation principles and adaptation of practices of individualization and informed consent, including involvement of relevant family or cultural members to effectively address barriers. Other strategies emphasized providing services and experiences through which informed decisions about services could occur and help the CRP make its services fully accessible and culturally appropriate for potential consumers. And, other strategies emphasized the importance of actively engaging and serving customers in an ethical and responsible manner. Multiple strategies were very frequently proposed by CRP staff to overcome interconnected barriers that limit access, participation, and outcomes. These complex strategies parallel the above findings that barriers likely derive from the person, families Within Consumer Status and History Disability, including diagnosed, undiagnosed disabilities, denial Medical status as fragile Employment history Current employment status Welfare status Criminal history Substance abuse history Attitudes, including trust Cultural identity, including acculturation Personal goals, including work and acculturation Personal motivation, expectations Others … Needs and Resources Basic needs, including housing, utilities, telephone, transportation Medical, health care needs Child and hospice care needs Reliance upon non-wage income and public resources Fear of potential loss of needed resources (e.g., health care, SSA) Economic resources, including money, discretionary income, savings Access to reliable transportation Knowledge held regarding rehabilitation systems, expectations, access Education and skills attained Literacy, reading and writing English Other languages spoken and read Independence and other functional issues Technology skills, including skills and access to computers Others … Within Cultural and Familial Environments Cultural Environment Culture of individual Cultural standards, prohibitions Traditions Expectations of members Concepts of disability, time, etc. Others … Familial Environment Family economic needs Preferences, expectations Fear, trust, cultural mistrust Knowledge held by family members of systems Language spoken, read (non-English, sign, Spanish) Family support, encouragement Others… Table 1 Locus of Origin of Barriers for Hispanics/Latinos (Examples Included) Within Broader Social and Physical Environment Social Commitment to accessibility Community attitudes, fear (e.g., toward segregation, minorities, immigrants) Racism Disincentives, stigma (bias and attitude toward) Employment outlook Employer receptivity Economic incentives Advocacy Others … Physical Resources available (funding, fiscal, programs, housing) Housing Education and training accessibility Medical service accessibility Law enforcement, public security Transportation systems Ethnic or disability supports and resources Availability of alternative service providers Others … Within Service Delivery Systems Environments VR System Eligibility regulations and requirements Decision making and referral processes Counselor personal traits Professionalism and competence of staff Caseloads (size, mix, preferences) Clarity and accessibility of information Outreach strategies Community standing or public knowledge of Budget and resources for services Standards and expectations of CRPs Policies respective to population and use of CRP services Relationships with related agencies, including providers Others … CRP Provider System Availability (alternatives, where services are located) Appropriateness (including culturally appropriate) Quality (perceived or known) Responsiveness of CRPs and staff Culturally appropriate services Cultural accessibility Receptivity of target populations Geographic accessibility Mission of organization Inclusion and exclusion policies Professionalism and competence of staff, including bilingualism of staff Cultural and linguistic similarity of CRP staff and board Others … and culture, community-at-large, the systems that attempt to provide services to Hispanic/Latino consumers and others in combination. Favored were strategies that focused on community outreach and development, quality and cultural relevance of services, on professional and cultural competence of personnel, and on geographic and cultural accessibility. Such types of strategies appear to have greater applicability for developing culturally responsive services and could increase the likelihood of affecting barriers that interfere with Hispanic/Latino and other minority access and full utilization of rehabilitation services. Strategies appropriate to a given community, CRP, and cultural group we suspect will likely emphasize CRP presence and connection within its community (mission, community connectedness, inclusivity, communications); specific services and resources the CRP directs toward cultural accessibility (orientation, comprehensiveness and equality in access to services, individualization, specialized services and supports); and capacity of the CRP to anticipate, change, and pursue future relevance to its consumers (staffing, training for staff development, and continuous organizational development). CRP Presence and Connection to Community • Mission statements frame an internal environment in which to achieve diversity and provide external cues regarding CRP capability, intents, and actions to provide services relevant to community populations. • Community connectedness strategies include those of outreach, networking, and marketing to achieve geographic, physical, disability, and cultural accessibility within the community. • Inclusivity includes strategies to incorporate consumer, family, cultural, and community input into program design, relevance, and ultimately accountability. • Communications strategies include using interpreters and ensuring messages and information are in languages, signage, formats, and traditions valued by populations in order to develop trust, relevance, and clarity. Specific Services and Resources CRP Directs Toward Cultural Accessibility • Orientation strategies for consumers and family members and provided prior to and throughout services help develop understanding of expectations and processes and encourages goal directed participation of relevant constituents. • Comprehensiveness and equal access strategies focus upon making all services available to all consumers regardless of cultural heritage and making sure that those services are accessible in forms that are culturally relevant. • Individualization strategies focus planning and delivery of services in keeping with the interests and goals of individual consumers and attends equally to cultural as well as rehabilitation needs. • Specialized services and support often involve community outreach, family members, and networking to connect individuals into other organizations and help develop consumer expectations, experiences, and subsequently help them retain achieved goals and changes in status. Capacity of CRP to Anticipate, Change, and Achieve Future Relevance • Staffing strategies include increasing both the cultural and professional competence of the organization as a whole and increasing the congruence of service and management personnel in language, values, and heritage to better reflect the community profile. • Training and development strategies include equal emphasis on cultural knowledge and attitudes (present competence) and on increasing staff responsiveness and value Table 2 Expanded Framework for Classifying Barriers and Strategies to Increase Access, Participation, and Success for Hispanics/Latinos Consumers Interconnected Barrier Hierarchies Complex Strategies Locus or Origin of Barriers Context Presence Within Consumer General Mission Statements Status and History Community Specific Community Connectedness Needs and Resources Culture Specific Inclusivity Within Personal Environments Perspective Communications Cultural Consumer Services Familial Community Orientation Within Broader Environments Personnel Comprehensiveness and Equal Access Social Cross-Cultural Studies Individualization Physical Importance Specialized Services and Supports Within Service System Environments Important Capacity VR System Focused Sometimes Important Staffing CRP Provider Focused Unimportant Training and Development Organizational Development to emerging populations (future relevance). • Organizational development are action strategies that shape how the CRP pursues opportunities to increase relevance and quality while strategically addressing systemic resource issues involving the CRP, community, and related systems. Potential for an Expanded Framework for Barriers and Strategies This research adds further evidence that there are interconnected barriers (some identified) for individuals, CRPs, and communities to create access and incorporate diversity in service design and delivery. No single barrier stands out toward which a CRP’s resources might be concentrated. Multiple, interconnected barriers are evident for individuals who wish to participate and succeed in vocational rehabilitation services. No single strategy was commonly proposed to address such interconnected barriers. More often than not, related strategies will be organized to address the multiple barriers Hispanic/Latino individual encounter. Table 2 proposes a framework with which to classify interconnected barriers and the complex strategies that effectively address them. Interconnected barriers will continue to challenge CRPs that wish to have greater relevance to emerging cultural populations that could benefit from vocational rehabilitation services. Great interest remains to find strategies and guidance of use to CRPs and the state-federal program to improve outreach and success among populations that are increasingly becoming dominant within many communities. Clearly, it would be desirable to systematically collect and classify strategies according to barriers, populations, and contexts along with evidence of their contributions to increasing access, relevance, and quality of services sought by Hispanic/Latino consumers and others. We suggest that this framework may be a beginning toward better matching strategies that are pertinent to barriers for potential Hispanic/Latino consumers. Future applied research may use this framework to identify barriers of greatest relative importance, given origin, context, and perspective, and guide practitioners and advocates to commit energy and resources to strategies that have greatest likelihood to impact access, participation, and success among Hispanic/Latino consumers in the communities that CRPs and the state- federal program serve. Cited References and Resources Available from Project All products identified here are available through the UTPA website (http://www.utpanam.edu/dept/rehabri/). The web training program is provided through RCEP-UNT (http://www.crp.unt.edu/). Cited Papers Reed, J. M., Holloway, L., Leung, P., and, Menz, F. E. (2005). Barriers to the Participation of Hispanic/Latino Individuals in Community Rehabilitation Programs, Journal of Applied Rehabilitation, 2005, 36(2), 33-41. Reed, J. M., Holloway, L, Shefcik, T., Leung, P, Menz, F.E.,Wilson, K. (December, 2005). Increasing Capacity of Community Rehabilitation Programs to Serve Hispanic Individuals. Edinburg, TX: The University of Texas-Pan American, Rehabilitation Research Institute. Reed, J. M. August, 2004. Why Diversity Matters to Community Rehabilitation Programs. University of North Texas CRP Brief, Volume 3, Number 2. Training Resources Training Resources Reed, J. M., & Holloway, L. March, 2005. Diversity Training for Community Rehabilitation Programs (CRP's): A WebCT Course. Denton, TX: University of North Texas, Regional Continuing Education Program for Community Rehabilitation Programs. Reed, J. M., Cortez, M. 2004. Diversity Matters: A Training ToolKit for Community Rehabilitation Programs. Edinburg, TX: The University of Texas-Pan American, Rehabilitation Research Institute. Horsman, E. 2005. Expanding Diversity within Community Rehabilitation Programs: Barriers and strategies: An Annotated Bibliography. Unpublished manuscript. Edinburg, TX: The University of Texas-Pan American, Rehabilitation Research Institute. Starting May 1, 2006, you can download an electronic copy of the Rehabilitation Research Initiative (RRI) Monograph, Increasing Capacity of Community Rehabilitation Programs to Serve Hispanic Individuals at http://www.utpanam.edu/dept/rehabri. If you’d like a copy of the RRI Monograph in Adobe PDF format on CD or a hardcopy of the Monograph please email your request to Mr. Tom Shefcik, Interim Chair, Department of Rehabilitation, The University of Texas- Pan American at tshefcik@panam.edu. Please include your mailing address in the email. Interested in a Career Counseling People With Disabilities? The Department of Rehabilitation at The University of Texas-Pan American offers a 48 hour, nationally accredited Master of Science Degree in Rehabilitation Counseling. Degree Highlights: • A chance to make a positive difference in a person’s life. • Employment in a variety of settings including, State Rehabilitation Agencies, Substance Abuse Prevention/Treatment, Private Rehabilitation, Community Rehabilitation Programs, Schools. • Eligible to sit for Certification as a Rehabilitation Counselor and obtain coursework for License as a Professional Counselor depending upon the state. • Competitive scholarships ($800) a month stipend plus tuition and fees. • Entry-level annual salaries averaging $30,000-$35,000. The Department also offers a Bachelor of Science Degree in Rehabilitative Services and an option for a concentration in Addiction Studies. For more information please call (956) 316-7036; email: rehabservic@panam.edu; Web: http://www.panam.edu/dept/rehabser/. The University of Texas-Pan American Department of Rehabilitation 1201 W. University Dr. Edinburg, TX 78541 Disclaimer Preparation of this RRI Brief was partially supported under grant funding from the Rehabilitation Services Administration, Office of Special Education and Rehabilitative Services (H315D0200003), U. S. Department of Education. The ideas, conclusions, and recommendations expressed herein are not to be taken as the opinions or policy of the U. S. Department of Education.