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Students With Intellectual Disability in Higher Education: Adult Service Provider Perspectives Kathleen Sheppard-Jones, Harold Lawrence Kleinert, Wendy Druckemiller, and Megan Kovacevich Ray
Abstract Postsecondary education (PSE) is increasingly becoming an option for students with intellectual disability (ID; Grigal & Hart, 2012). Postsecondary education offers the promise of pursuing a valued social role (that of college student), enhanced social networks, and, most significantly, increased employment options. To date, research and practice in the area of transition to PSE for students with ID has focused primarily upon the sending (public school systems) and receiving (colleges or universities) agencies (Oertle & Bragg, 2014; Thoma et al., 2011). Yet adults with ID often require ongoing supports through state and federally funded developmental disability waivers, and agency providers of waiver services have, for the most part, not been part of this vital conversation. This study represents an exploratory study of directors of developmental disability provider agencies in one midwestern state to assess their knowledge of PSE for individuals with ID. A total of 87 directors responded; quantitative results are presented and, based on these findings, we provide implications for the future. Key Words: higher education; postsecondary education; adult providers; intellectual disability
Introduction Inequities in life opportunities for individuals with intellectual disability (ID) have been well documented throughout history (Wolfensberger, 1972). It is only within the last 40 years that there has been any expectation that students with the most significant ID would even attend school, let alone learn side-by-side with their nondisabled peers (Heward, 2013). A heightened focus on transition and the importance of work has also translated into a variety of school-to-career possibilities, though students with ID are less likely to attain competitive jobs (Wagner, Newman, Cameto, Levine, Garza, 2006) and especially less likely to participate in higher education (Grigal, Hart, & Migliore, 2011). Amendments to the Individuals With Disabilities Education Act (IDEA) in 1990 mandated that every secondary-aged student receiving special education services have school-to-postschool transition planning incorporated into their individualized education program (IEP). Specifically, publicly supported education for students with disabilities should conclude with postschool em-
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ployment and independent living—including postsecondary education as needed and appropriate to their career goals (Certo et al., 2008). In the subsequent reauthorizations of IDEA in 1997 and 2007, Congress has continued to recognize the fundamental importance of transition planning and, specifically, the role of adult service providers as integral to successful transitions.
Postsecondary Education for Students With Intellectual Disability There is evidence that completing almost any type of postsecondary education significantly improves an individual’s chances of securing meaningful employment (Gilson, 1996; National Council on Disability and Social Security Administration, 2000). Analysis of national vocational rehabilitation data found that ‘‘youth with ID who participated in postsecondary education were 26% more likely to leave vocational rehabilitation services with a paid job and earn a 73% higher weekly income’’ (Migliore, Butterworth, & Hart, 2009, p. 1). Zafft, Hart, and Zimbrich (2004) found that, for 20 transition age students
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with ID, participation in postsecondary programs with individual supports resulted in higher employment rates (100% vs. 43%) and higher wages compared to similar students who were served in a more traditional high-school-based transition program. Moreover, students who participate in PSE are less likely to need ongoing supports as they move on with their lives and into the roles of employees (Zafft et al., 2004). Yet, less than 5 years ago, only 2% of youth with ID were enrolled in some form of PSE (National Longitudinal Transition Study-2, 2009). Given the fact that higher education has been considered a successful transition outcome for over 15 years under IDEA, the notion of a student with ID actually attending a college or university has perhaps been more an idea than a reality. Given the fact that successful transition to PSE and/or employment involves both school systems and adult service providers, it is important that we understand the new options available to students with ID under the Higher Education Opportunities Act of 2008 (HEOA), as well as the knowledge and perspectives of adult service providers about those opportunities, if we expect increasing numbers of students with ID to have this option in their lives.
Higher Education Opportunities Act of 2008 The reauthorization of the HEOA has provided further impetus and opportunities for students with ID to participate in PSE. The HEOA includes specific language related to students with ID and their access to higher education, even if they have not completed a regular high school diploma or they are not pursuing a standard 2- or 4-year academic degree. This also provides access for students with more significant ID, who may not have earned a standard high school diploma. It has also opened the door to fund grants to develop concerted opportunities with colleges and universities around the nation in promoting a meaningful credential for students with ID who choose to pursue higher education. Comprehensive Transition Programs. Through the provisions of the HEOA, new mechanisms of support within the higher education system are emerging. Comprehensive Transition Programs (CTPs) were first outlined in that legislation. CTPs provide a new entryway into colleges and universities for students with ID who may not have received
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a traditional high school diploma, or who would otherwise be unable to meet entrance requirements. CTPs exist as an offering within a college and are intended to promote employment through academic, career, and independent living offerings (Think College, n.d.). A unique hallmark of a CTP is that it does not require students with ID to be admitted utilizing the traditional college entrance mechanism. Although CTPs may have different approaches (e.g., some focus on students residing on campus; others provide coursework and extracurricular activities for commuting students), all CTPs provide students with ID the opportunity to access federal financial aid (e.g., Pell Grants, Federal Work-Study) while enrolled. This represents a new access point to higher education with a viable means to help pay for that education. CTPs also provide for students to earn a ‘‘meaningful credential’’ (through a combination of for-credit and/ or audited classes and work internships); these credentials are individualized to the needs of the student and are designed to enhance employment opportunities in a career of the student’s choosing. The focus of CTPs is on career education for students with ID in a career of their choice. Students have individually planned programs that may include either audited or for-credit classes reflecting their career internships, planned internships throughout their program directly related to their career choice, and opportunities for extracurricular involvement with their college-age peers (Kleinert, Jones, Sheppard-Jones, Harp, & Harrison, 2012). In addition, postsecondary programs often include peer mentors, who provide targeted supports to students with ID in their coursework and in their participation throughout college life (Jones & Goble, 2012; Kleinert et al., 2012).
Emerging Recognition of Postsecondary Options and Adult Provider Agencies The new opportunities in the provisions of HEOA have sparked a dialogue among families, students with ID, and professionals in both the secondary and postsecondary education systems. Yet it is also an area that must be explored by state developmental disability agencies and providers of adult services. As Hart, Zimbrich, and Whelley (2002, p. 2) noted ‘‘Educators, adult service agencies, and service providers face barriers to collaboration, including a lack of knowledge regarding each other’s systems as well as bureaucratic constraints
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resulting from long waiting lists and limited financial resources.’’ Therefore, it is highly likely that, if concerted efforts to promote postsecondary options for adults with ID don’t involve adult service providers as valued stakeholders, many individuals with ID who would benefit from the opportunity will not seek out higher education as a possible option at all. Early research shows that collaboration with service providers needs to be a central element of planning for systemic change in this area (Mock & Love, 2012). Traditionally, adult day supports have not been provided on college campuses, though this does represent an obvious community access locale for normalized, ageappropriate, and valued services. As adult service provision evolves, adult provider agencies will need an increased understanding of postsecondary options for students with ID and an increased role in transition planning to enable students with ID to participate in that option. Postsecondary education is more than simply having physical access to a particular course or college classroom, but, rather, is about the improved outcomes that are available to students, including the ability of students to set goals for their own learning, career, and relationships (Grigal & Hart, 2010). Because adult service providers may not have previously been involved in the conversation and because these providers can provide an important mechanism for sharing information with adults with ID whom they serve, it is important to determine the level of awareness of providers related to students with ID and higher education. This study seeks to assess the current knowledge and attitudes about higher education and people with ID held by provider agencies of ID services and supports in one midwestern state. Specifically, we developed our survey to address two primary research questions: 1.
2.
To what extent ID provider agencies perceive that students with ID can benefit from participating in PSE. To what extent provider agencies are aware of the options for students with ID in attending college, especially under the provisions of the HEOA.
Methods Participants Participants in this study were directors of agencies that provide case management or other services to
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adults on the state’s Medicaid waiver for people with ID. Participants were selected using the state’s email listing of 155 Medicaid provider agencies. A total of 87 agency directors took part in this study. This represents a survey response rate of 56% of eligible respondents. The average age of respondents was 44.3 years old. Their ages ranged from 24 to 66 years old (SD 5 11.3). An overwhelming majority of those completing the survey were female (83.7%), while less than 1 in 5 was male (16.3%).
Instruments, Procedures, and Variables The questionnaire for this study was designed to collect data on adult ID provider agency providers’ knowledge, experiences, and perceptions of PSE. It also addressed gaps in knowledge or perceived needs. The authors developed the survey using an expert panel from Kentucky’s Transition and Postsecondary Program for Students With ID (TPSID), as no existing adult ID provider PSE measure was located. An expert panel can be an efficient, low-cost method of survey pretesting (Yan, Kreuter, & Tourangeau, 2012). The expert panel reviewed and provided revisions to the survey instrument. The survey was created using SurveyMonkey and contained a total of 22 items. Items were short answer (i.e., fill in the blank), forced choice, and ratings on a 5-point Likert scale (1 5 strongly agree, 5 5 strongly disagree). Six items were demographic. Seven items were related to provider agency experiences with PSE for individuals with ID. Two items assessed attitudes about PSE. Four items assessed knowledge. Two items related to perceived needs and resources were also included. The final item allowed the respondent to provide any additional open-ended comments. The dataset was stripped of IP addresses and respondents were not asked to self-identify. The survey and research procedures were approved by the University of Kentucky’s Institutional Review Board prior to survey administration. The state maintains an email list of all Medicaid provider agency directors. An email was sent by a staff member of the state developmental disability agency to everyone on the list, requesting participation in a brief online survey. A link to the survey was provided in the email. A follow-up email, thanking those who had completed the survey and asking those who had not submitted the survey to do so was sent 2 weeks following the
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initial email to the entire distribution list. The survey was open to respondents for 29 days. A total of 87 surveys were completed, all of which were useable, resulting in a final response rate of 56.1% (N 5 155).
sample respondents, their agency, and the individuals they serve. The second section includes results of exploratory analysis. Demographic responses are found in Table 1. Table 2 contains knowledge and attitude responses.
Data Analyses
Descriptive Characteristics
The Statistical Package for the Social Sciences (SPSS) Version 19 was used for all data analysis. Descriptive statistics were computed to examine the data. Frequency results were run on the nominal demographic variables; the Likert scale responses for the attitudes and knowledge items were averaged; and bivariate correlations were conducted for attitudes and knowledge items, years in the field, and respondent age. Comparisons were not made across agency types, as many agencies indicated that they provided multiple services (i.e., residential, day habilitation, community living, and supported employment).
Respondents were asked how long they have worked in the rehabilitation field. Answers ranged from 2 years to 39 years, with a mean of 13.5 years of experience (SD 5 9.41). Participants were asked to describe the geographic location of their agency. Over half (51.8%) described their setting as rural. Provider agencies showed a wide range in the numbers of people served by the agency, from two to 1,100 (n 5 83, mean 5 107.3, SD 5 219.94). Agency services provided included: day habilitation (65.5%), residential (58.6%), community living support (58.6%), and supported employment (40.2%). Other provided services were: case management (32.2%), respite (23%), behavior supports (11.5%), and various therapies (4.6%). Agency directors were asked if anyone they served had expressed an interest in continuing their education. The majority did (70.1%). Those who answered ‘‘yes’’ were asked how many individuals whom they served wanted to continue their education. Responses ranged from one person to 55 people (n 5 61; mode 5 2). When taking agency size into account (i.e., dividing the number of individuals interested in pursuing their education by the total number of individuals served by that agency), individuals who indicated that they
Results The intent of this study was to explore the knowledge and attitudes of adult provider agencies. It also was intended to provide data that would serve as a foundation for further exploration of a key entity that brings particular attributes and strengths to the realm of PSE for individuals with ID. This is of special interest, given that there is not currently existing data that address the experiences of this study’s target population. Results are presented in two sections. The first section includes descriptive demographic characteristics of the Table 1 Basic Sample Characteristics Variable Years in field Age Served Gender Men Women Agency location Urban Suburban Rural Clients expressing interest in higher education Provider was involved in the transition process
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%
N
Mean
SD
86 87 87 86
14.4 44.3 119.4
9.61 11.28 219.94
16.3 83.7 85 27.1 21.2 51.8 70.1 33.3
61 29
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Table 2 Knowledge and Attitude Items Variable
N
Average Rank
SD
Individuals with ID can benefit from participating in higher education Provider agencies understand PSE is an option for individuals with ID I am aware of the reauthorization of the HEOA and what it means for individuals with ID Families understand that PSE is an option for individuals with ID Individuals with ID are unlikely to succeed in PSE
86 87 86
1.56 2.29 3.07
.64 1.09 1.02
87 87
3.09 3.75
1.01 .82
Note. ID 5 Intellectual disability; PSE 5 Postsecondary education; HEOA 5 Higher Education Opportunity Act. Rank: 1 5 strongly agree, 5 5 strongly disagree. wanted to continue their education represented a range of less than one percent up to 30% of those served by the agency. In fact, 21.8% of the directors responded that they served someone who was currently in college or technical school, with most having one person attending school (n 5 17; mode 5 1). Courses that were being taken included: general education and introductory level courses such as English and algebra, music composition, art, computer, public speaking, first aid, vocational automotive, and high school and GED (though the latter two do not fit with the definitions of college or technical school courses). One-third of respondents (33.3%) had helped a person with ID in the process of transitioning into college or a technical school. Agency directors were asked to rate their level of agreement on a series of statements related to PSE and people with ID. Responses were on a 5point Likert-type scale where 1 5 strongly agree, 2 5 agree, 3 5 neutral, 4 5 disagree, and 5 5 strongly disagree. Complete results can be found in Table 2. Respondents were most in agreement with the item ‘‘Individuals with intellectual disabilities can benefit from participating in higher education’’ (M 5 1.56, SD 5 .64). In fact, 92% of agency directors agreed or strongly agreed with this item. The lowest-ranked item was ‘‘Individuals with ID are unlikey to succeed in postsecondary education’’ (M 5 3.75, SD 5 .82). Additionally, although 69% of agency directors agreed or strongly agreed that their agencies understood PSE as an option for the persons they served, respondents agreed that only 34% of family members understood that PSE was an option. Agency directors indicated that a variety of resources would be helpful to increase their
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confidence in advising individuals with ID about continuing their education, with information on available supports (80.5%), funding (77%), and accessing PSE (72.4%) being the most needed. Respondents also indicated that, if they had a person interested in PSE, they would seek resources from a college or technical school disability support services office (74.7%) and the state office of vocational rehabilitation (70.1%).
Exploratory Analysis Because many agencies provided both day and residential services, further comparison between these groups was not completed. However, t-tests were conducted to determine if differences could be found between agencies that considered themselves rural or urban. No statistically significant differences were found on any items. As might be expected, a strong positive correlation was found between age and years worked in the field (r 5 .479, a 5 .01). No significant correlations were found between the number of years in the field and awareness items on this survey, suggesting that length of time working in the disability arena does not impact one’s knowledge of resources. However, age of respondent was moderately negatively correlated with the statement, ‘‘Realistically, individuals with intellectual disabilities are unlikely to succeed in postsecondary education’’ (r 5 2.381, a 5 .01). In other words, older respondents were more likely to have more positive expectations of people with ID in higher education. There was a strong correlation between provider agencies’ understanding of PSE and provider’s perception of the family understanding of PSE (r 5 .591, a 5 .01). There was also a strong
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correlation between family understanding of PSE and provider understanding of the HEOA and implications for people with ID (r 5 .474, a 5 .01). As would be expected, there was also a positive correlation between provider agency understanding of PSE and of provider understanding of the HEOA (p 5 .397, a 5 .01). These correlations are found in Table 3.
Discussion The results of this study show that adult service providers in one midwestern state have a great deal of interest in PSE for the adults with ID they serve. One finding was that those with a longer history working in the developmental disability field appear to more strongly agree that individuals with ID can benefit from higher education. This reemphasizes the need for additional training and resources to introduce the notion of PSE to providers. This includes addressing some of the common questions around entrance requirements and ability to access courses of interest when prerequisites stand in the way. This may be especially true for those professionals who have not been exposed to the idea of people with ID continuing on as learners into adulthood. Providers rated themselves as having a greater understanding of postsecondary opportunities for individuals with ID than they rated the understanding of family members in this area. Yet, given the integral role of families in supporting transition
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planning for youth with significant disabilities, as well as the role of parental expectations in shaping youth outcomes (Doren, Gau, & Lindstrom, 2012), knowledge of families about PSE at the point of transition is critical. We are at an important crossroads. There is dialogue taking place among stakeholders. Leadership within institutions of higher education is a vital component of fostering an environment that is welcoming of all learners. Secondary educators and families must have expectations that include higher education as a viable option for students and youth with ID. Individuals with ID must be motivated to continue their education beyond high school. Yet integral partners should also include providers of Medicaid waiver services who provide supports to young adults with ID once the secondary school career has concluded. These community-based providers must be included in the discussions to enhance their understanding of not only legislation and use of waiver funds to support students in higher education, but to recognize postsecondary education as a viable means of improving quality of life, through increased community connectedness, expanding social networks, elevated employment possibilities, and improved self-efficacy. The practice of including adult service provider agencies at the outset is an important factor in helping the student developing his or her college plans so that the planning includes time for classes, tutoring, extracurricular activities, volunteering,
Table 3 Knowledge and Attitude Correlates Measure
1
2
3
4
5
6
1. Individuals with ID can benefit from participating in 1 high education 2. Provider agencies understand PSE is an option for .12 1 individuals with ID 3. Families understand that PSE is an option for .11 .591* 1 individuals with ID 4. Individuals with ID are unlikely to succeed in PSE 2.37* 2.074 2.029 1 5. I am aware of the reauthorization of the HEOA and .065 .397* .47* 2.021 1 what is means for individuals with ID 6. Years in field 2.1 .02 2.02 2.21 2.15 1 7. Age .16 .02 2.05 2.37 2.18 .479*
7
1
Note. ID 5 Intellectual disability; PSE 5 Postsecondary education; HEOA 5 Higher Education Opportunity Act. *Significant at the .01 level.
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internships, and other facets of college life. Agencies that provide day and residential supports can also play a key role in navigating transportation issues. Indeed, a sense of belonging in the community of adult learners and an opportunity to pursue one’s goals and dreams are at the heart of PSE (CaustonTheoharis, Ashby, & DeClouette, 2009).
Limitations This study represented an exploratory survey in one state. Survey items were developed by an expert panel, composed of one state’s TPSID grant. Moreover, participants self-selected for this voluntary online survey. Although online surveys provide ease in development and distribution, the target population may not be responsive, particularly given the volume of online communications (Dillman, Smyth, & Christian, 2009). It is possible that those who did not respond had far different levels of knowledge or attitudes, though it is not likely that nonrespondents would have evidenced a greater awareness of PSE opportunities for students with ID than those who did respond. It is also possible that respondents answered the items in a way that they perceived as responding in the most socially appropriate way. Technology constraints of potential respondents may also have limited the response rate. This survey was also conducted approximately a month following an online provider training on higher education opportunities for students with intellectual disability in that state. Therefore, these results should be viewed with caution and as a snapshot in time, and may not be representative of adult service providers in other states. This study does serve, however, as a good starting point upon which to build further dialogue.
Implications for the Future The repository of knowledge related to PSE and ID is growing quickly. As of February 2014, nearly 30 CTPs have been approved, with many more in the application process. Although the offerings provided by these entities may vary by school, their overarching goal of providing a meaningful credential for students with ID is universal. This study provides an initial examination of perspectives of adult service providers. This set of stakeholders has a valuable perspective on the current service delivery system, along with insights into systemic issues that may either impede or promote successful transition into PSE. National and state-level
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resources must be made available to adult service provider agency personnel, so that they can be knowledgeable and supportive in conversations around higher education. Collaboration and a holistic approach to the provision of services for people with ID can best support the needs and wants of the whole person, including the opportunity to pursue PSE. We are encouraged that the vast majority of agency directors (92%) who responded to our survey believed that individuals with ID can benefit from participation in higher education. Further, 69% agreed that they had some understanding of PSE opportunities for individuals with ID, and that they perceived PSE as an important option for at least some of their clients. Awareness of this option and its potential benefits is a first step. The survey data presented here suggest the potential impact of dissemination and technical assistance efforts to maximize the involvement and understanding of adult services providers. Agencies can be provided with examples of adults with ID who are achieving success in PSE settings and, as a result, experiencing improved life outcomes. Information dissemination can also be used to demonstrate how the blending of separate funding streams, including Federal Pell Grants and Work-Study through university participation in a CTP, state vocational rehabilitation funds, Medicaid Waiver Services, and perhaps state scholarship funds provided to all students, can be ‘‘braided’’ through interagency agreements to create carefully crafted supports at the individual level. Adult service providers are valuable partners in the process for systems change in the area of higher education for people with ID. Training opportunities for these professionals may also result in increased awareness of PSE by families and individuals with ID. This survey found that providers rated families as considerably less knowledgeable of postsecondary educational options than the providers rated themselves. By training providers, and especially case managers, on the new possibilities available to adults with ID in PSE, the families of those served by the agency can also be ultimately impacted. Families and selfadvocates can provide powerful impetus for the further expansion of this endeavor. University Centers for Excellence in Developmental Disabilities (UCEDDs) can be valuable partners in this effort, along with Think College (www. ThinkCollege.net). The role of adult service providers will become increasingly important if
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we are to expand postsecondary educational opportunities for youth with ID and, ultimately, to enhance their life outcomes through PSE experiences, when that is the dream of the individual. This exploratory study is a small step in engaging adult providers in that essential conversation.
References Causton-Theoharis, J., Ashby, C., and DeClouette, N. (2009). Relentless optimism: Inclusive postsecondary opportunities for students with significant disabilities. Journal of Postsecondary Education and Disability, 22(2), 88–105. Certo, N., Luecking, R., Murphy, S., Brown, L., Courey, S. & Belanger, D. (2008). Seamless transition and long-term support for individuals with severe intellectual disabilities. Research and Practice for Persons with Severe Disabilities, 33(3), 88–95. http://dx.doi.org/10.2511/rpsd.33.3.85 Dillman, D. A., Smyth, J., & Christian, L. M. (2009). Internet, mail, and mixed-mode surveys: The tailored design method (3rd ed.). Hoboken, NJ: Wiley. Doren, B., Gau, J., & Lindstrom, L. (2012). The relationship between parent expectations and postschool outcomes of adolescents with disabilities. Exceptional Children, 79, 7–23. Gilson, S. F. (1996). Students with disabilities: An increasing voice and presence on college campuses. Journal of Vocational Rehabilitation, 6(3), 263–272. Grigal, M., & Hart, D. (2012). The power of expectations. Journal of Policy and Practice in Intellectual Disabilities, 9(4), 221–222. http://dx. doi.org/10.1111/jppi.12014 Grigal, M., Hart, D., & Migliore, A. (2011). Comparing the transition planning, postsecondary education, and employment outcomes of students with intellectual and other disabilities. Career Development for Exceptional Individuals, 34(1), 4–17. http://dx.doi.org/10.1177/ 0885728811399091 Grigal, M., & Hart, D. (2010). What’s the point? A reflection about the purpose and outcomes of college for students with intellectual disabilities [Think College Insight Brief No. 2]. Boston, MA: University of Massachusetts Boston, Institute for Community Inclusion. Hart, D., Zimbrich, K., & Whelley, T. (2002). Challenges in coordinating and managing services
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and supports in secondary and postsecondary options [Issue Brief Vol. 1, No. 6]. Minneapolis, MN: National Center on Secondary Education and Transition. Heward, W. (2013). Exceptional children: An introduction to special education (10th ed.). Upper Saddle River, NJ: Pearson. Higher Education Opportunities Act, Pub. L. 110315, 20 U.S.C. § 1001 (2008). IBM SPSS Statistics for Windows (Version 19.0) [Computer software]. Armonk, NY: IBM Corp. Individuals With Disabilities Education Act, 20 U.S.C. §§ 1400 (2007). Jones, M., & Goble, Z. (2012). Creating effective mentoring partnerships for students with intellectual disabilities on campus. Journal of Policy and Practice in Intellectual Disabilities, 9(4), 270– 278. http://dx.doi.org/10.1111/jppi.12010 Kleinert, H., Jones, M., Sheppard-Jones, K., Harp, B., & Harrison, M. (2012). Students with intellectual disabilities going to college? Absolutely! Teaching Exceptional Children, 44 (5), 26–35. Migliore, A., Butterworth, J. & Hart, D. (2009). Postsecondary education and employment outcomes for youth with intellectual disabilities [Think College Fast Facts No. 1]. Boston, MA: University of Massachusetts Boston, Institute for Community Inclusion. Mock, M., & Love, K. (2012). One state’s initiative to increase access to higher education for people with intellectual disabilities. Journal of Policy and Practice in Intellectual Disabilities, 9(4), 289– 297. http://dx.doi.org/10.1111/jppi.12006 National Council on Disability and Social Security Administration. (2000). Transition and postschool outcomes for youth with disabilities: Closing the gaps to postsecondary education and employment. Washington, DC: Authors. National Longitudinal Transition Study-2. (2009). NLTS-2 wave 5 parent/youth survey data tables. Retrieved from www.mlts2.org/data_tables/ index.html Oertle, K. M. & Bragg, D. D. (2014). Transitioning students with disabilities: Community college policies and practices. Journal of Disability Policy Studies, 25(1), 1–9. http://dx.doi.org/10.1177/ 1044207314526435 Think College. (n.d.) Becoming a Comprehensive Transition Program. Retrieved from http:// www.thinkcollege.net/topics/becoming-acomprehensive-transition-program
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Thoma, C. A., Lakin, C. K., Carlson, D., Domzal, C., Austin, K., & Boyd, K. (2011). Participation in postsecondary education for students with intellectual disabilities: A review of the literature 2001–2010. Journal of Postsecondary Education and Disability, 24(3), 175–191. Wagner, M., Newman, L., Cameto, R., Levine, P., & Garza, N. (2006). An overview of findings from wave 2 of the National Longitudinal Transition Study-2 (NLTS2) [NCSER 20063004]. Menlo Park, CA: SRI International. Retrieved from http://www.nlts2.org/reports/ 2006_08/nlts2_report_2006_08_complete.pdf Wolfensberger, W. (1972). The principle of normalization in human services. Toronto, Canada: National Institute on Mental Retardation. Yan, T., Kreuter, F., & Tourangeau, R. (2012). Evaluating survey questions: A comparison of methods. Journal of Official Statistics, 28(4), 503–529. Zafft, C., Hart, D. & Zimbrich, K. (2004). College career connection: A study of youth
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with intellectual disabilities and the impact of postsecondary education. Education and Training in Developmental Disabilities, 39(1), 45–53.
Received 2/4/2014, accepted 1/9/2015. Authors: Kathleen Sheppard-Jones and Harold Lawrence Kleinert, University of Kentucky, Human Development Institute; Wendy Druckemiller, Centerstone; and Megan Kovacevich Ray, Trilogy Behavioral Healthcare. Correspondence concerning this article should be addressed to Kathleen Sheppard-Jones, University of Kentucky, Human Development Institute, 210 Mineral Industries Bldg., Lexington, Kentucky 40506, USA (e-mail: [email protected]).
Provider Perspectives
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Students With Intellectual Disability in Higher Education: Adult Service Provider Perspectives Kathleen Sheppard-Jones, Harold Lawrence Kleinert, Wendy Druckemiller, and Megan Kovacevich Ray
Abstract Postsecondary education (PSE) is increasingly becoming an option for students with intellectual disability (ID; Grigal & Hart, 2012). Postsecondary education offers the promise of pursuing a valued social role (that of college student), enhanced social networks, and, most significantly, increased employment options. To date, research and practice in the area of transition to PSE for students with ID has focused primarily upon the sending (public school systems) and receiving (colleges or universities) agencies (Oertle & Bragg, 2014; Thoma et al., 2011). Yet adults with ID often require ongoing supports through state and federally funded developmental disability waivers, and agency providers of waiver services have, for the most part, not been part of this vital conversation. This study represents an exploratory study of directors of developmental disability provider agencies in one midwestern state to assess their knowledge of PSE for individuals with ID. A total of 87 directors responded; quantitative results are presented and, based on these findings, we provide implications for the future. Key Words: higher education; postsecondary education; adult providers; intellectual disability
Introduction Inequities in life opportunities for individuals with intellectual disability (ID) have been well documented throughout history (Wolfensberger, 1972). It is only within the last 40 years that there has been any expectation that students with the most significant ID would even attend school, let alone learn side-by-side with their nondisabled peers (Heward, 2013). A heightened focus on transition and the importance of work has also translated into a variety of school-to-career possibilities, though students with ID are less likely to attain competitive jobs (Wagner, Newman, Cameto, Levine, Garza, 2006) and especially less likely to participate in higher education (Grigal, Hart, & Migliore, 2011). Amendments to the Individuals With Disabilities Education Act (IDEA) in 1990 mandated that every secondary-aged student receiving special education services have school-to-postschool transition planning incorporated into their individualized education program (IEP). Specifically, publicly supported education for students with disabilities should conclude with postschool em-
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ployment and independent living—including postsecondary education as needed and appropriate to their career goals (Certo et al., 2008). In the subsequent reauthorizations of IDEA in 1997 and 2007, Congress has continued to recognize the fundamental importance of transition planning and, specifically, the role of adult service providers as integral to successful transitions.
Postsecondary Education for Students With Intellectual Disability There is evidence that completing almost any type of postsecondary education significantly improves an individual’s chances of securing meaningful employment (Gilson, 1996; National Council on Disability and Social Security Administration, 2000). Analysis of national vocational rehabilitation data found that ‘‘youth with ID who participated in postsecondary education were 26% more likely to leave vocational rehabilitation services with a paid job and earn a 73% higher weekly income’’ (Migliore, Butterworth, & Hart, 2009, p. 1). Zafft, Hart, and Zimbrich (2004) found that, for 20 transition age students
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with ID, participation in postsecondary programs with individual supports resulted in higher employment rates (100% vs. 43%) and higher wages compared to similar students who were served in a more traditional high-school-based transition program. Moreover, students who participate in PSE are less likely to need ongoing supports as they move on with their lives and into the roles of employees (Zafft et al., 2004). Yet, less than 5 years ago, only 2% of youth with ID were enrolled in some form of PSE (National Longitudinal Transition Study-2, 2009). Given the fact that higher education has been considered a successful transition outcome for over 15 years under IDEA, the notion of a student with ID actually attending a college or university has perhaps been more an idea than a reality. Given the fact that successful transition to PSE and/or employment involves both school systems and adult service providers, it is important that we understand the new options available to students with ID under the Higher Education Opportunities Act of 2008 (HEOA), as well as the knowledge and perspectives of adult service providers about those opportunities, if we expect increasing numbers of students with ID to have this option in their lives.
Higher Education Opportunities Act of 2008 The reauthorization of the HEOA has provided further impetus and opportunities for students with ID to participate in PSE. The HEOA includes specific language related to students with ID and their access to higher education, even if they have not completed a regular high school diploma or they are not pursuing a standard 2- or 4-year academic degree. This also provides access for students with more significant ID, who may not have earned a standard high school diploma. It has also opened the door to fund grants to develop concerted opportunities with colleges and universities around the nation in promoting a meaningful credential for students with ID who choose to pursue higher education. Comprehensive Transition Programs. Through the provisions of the HEOA, new mechanisms of support within the higher education system are emerging. Comprehensive Transition Programs (CTPs) were first outlined in that legislation. CTPs provide a new entryway into colleges and universities for students with ID who may not have received
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a traditional high school diploma, or who would otherwise be unable to meet entrance requirements. CTPs exist as an offering within a college and are intended to promote employment through academic, career, and independent living offerings (Think College, n.d.). A unique hallmark of a CTP is that it does not require students with ID to be admitted utilizing the traditional college entrance mechanism. Although CTPs may have different approaches (e.g., some focus on students residing on campus; others provide coursework and extracurricular activities for commuting students), all CTPs provide students with ID the opportunity to access federal financial aid (e.g., Pell Grants, Federal Work-Study) while enrolled. This represents a new access point to higher education with a viable means to help pay for that education. CTPs also provide for students to earn a ‘‘meaningful credential’’ (through a combination of for-credit and/ or audited classes and work internships); these credentials are individualized to the needs of the student and are designed to enhance employment opportunities in a career of the student’s choosing. The focus of CTPs is on career education for students with ID in a career of their choice. Students have individually planned programs that may include either audited or for-credit classes reflecting their career internships, planned internships throughout their program directly related to their career choice, and opportunities for extracurricular involvement with their college-age peers (Kleinert, Jones, Sheppard-Jones, Harp, & Harrison, 2012). In addition, postsecondary programs often include peer mentors, who provide targeted supports to students with ID in their coursework and in their participation throughout college life (Jones & Goble, 2012; Kleinert et al., 2012).
Emerging Recognition of Postsecondary Options and Adult Provider Agencies The new opportunities in the provisions of HEOA have sparked a dialogue among families, students with ID, and professionals in both the secondary and postsecondary education systems. Yet it is also an area that must be explored by state developmental disability agencies and providers of adult services. As Hart, Zimbrich, and Whelley (2002, p. 2) noted ‘‘Educators, adult service agencies, and service providers face barriers to collaboration, including a lack of knowledge regarding each other’s systems as well as bureaucratic constraints
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resulting from long waiting lists and limited financial resources.’’ Therefore, it is highly likely that, if concerted efforts to promote postsecondary options for adults with ID don’t involve adult service providers as valued stakeholders, many individuals with ID who would benefit from the opportunity will not seek out higher education as a possible option at all. Early research shows that collaboration with service providers needs to be a central element of planning for systemic change in this area (Mock & Love, 2012). Traditionally, adult day supports have not been provided on college campuses, though this does represent an obvious community access locale for normalized, ageappropriate, and valued services. As adult service provision evolves, adult provider agencies will need an increased understanding of postsecondary options for students with ID and an increased role in transition planning to enable students with ID to participate in that option. Postsecondary education is more than simply having physical access to a particular course or college classroom, but, rather, is about the improved outcomes that are available to students, including the ability of students to set goals for their own learning, career, and relationships (Grigal & Hart, 2010). Because adult service providers may not have previously been involved in the conversation and because these providers can provide an important mechanism for sharing information with adults with ID whom they serve, it is important to determine the level of awareness of providers related to students with ID and higher education. This study seeks to assess the current knowledge and attitudes about higher education and people with ID held by provider agencies of ID services and supports in one midwestern state. Specifically, we developed our survey to address two primary research questions: 1.
2.
To what extent ID provider agencies perceive that students with ID can benefit from participating in PSE. To what extent provider agencies are aware of the options for students with ID in attending college, especially under the provisions of the HEOA.
Methods Participants Participants in this study were directors of agencies that provide case management or other services to
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adults on the state’s Medicaid waiver for people with ID. Participants were selected using the state’s email listing of 155 Medicaid provider agencies. A total of 87 agency directors took part in this study. This represents a survey response rate of 56% of eligible respondents. The average age of respondents was 44.3 years old. Their ages ranged from 24 to 66 years old (SD 5 11.3). An overwhelming majority of those completing the survey were female (83.7%), while less than 1 in 5 was male (16.3%).
Instruments, Procedures, and Variables The questionnaire for this study was designed to collect data on adult ID provider agency providers’ knowledge, experiences, and perceptions of PSE. It also addressed gaps in knowledge or perceived needs. The authors developed the survey using an expert panel from Kentucky’s Transition and Postsecondary Program for Students With ID (TPSID), as no existing adult ID provider PSE measure was located. An expert panel can be an efficient, low-cost method of survey pretesting (Yan, Kreuter, & Tourangeau, 2012). The expert panel reviewed and provided revisions to the survey instrument. The survey was created using SurveyMonkey and contained a total of 22 items. Items were short answer (i.e., fill in the blank), forced choice, and ratings on a 5-point Likert scale (1 5 strongly agree, 5 5 strongly disagree). Six items were demographic. Seven items were related to provider agency experiences with PSE for individuals with ID. Two items assessed attitudes about PSE. Four items assessed knowledge. Two items related to perceived needs and resources were also included. The final item allowed the respondent to provide any additional open-ended comments. The dataset was stripped of IP addresses and respondents were not asked to self-identify. The survey and research procedures were approved by the University of Kentucky’s Institutional Review Board prior to survey administration. The state maintains an email list of all Medicaid provider agency directors. An email was sent by a staff member of the state developmental disability agency to everyone on the list, requesting participation in a brief online survey. A link to the survey was provided in the email. A follow-up email, thanking those who had completed the survey and asking those who had not submitted the survey to do so was sent 2 weeks following the
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initial email to the entire distribution list. The survey was open to respondents for 29 days. A total of 87 surveys were completed, all of which were useable, resulting in a final response rate of 56.1% (N 5 155).
sample respondents, their agency, and the individuals they serve. The second section includes results of exploratory analysis. Demographic responses are found in Table 1. Table 2 contains knowledge and attitude responses.
Data Analyses
Descriptive Characteristics
The Statistical Package for the Social Sciences (SPSS) Version 19 was used for all data analysis. Descriptive statistics were computed to examine the data. Frequency results were run on the nominal demographic variables; the Likert scale responses for the attitudes and knowledge items were averaged; and bivariate correlations were conducted for attitudes and knowledge items, years in the field, and respondent age. Comparisons were not made across agency types, as many agencies indicated that they provided multiple services (i.e., residential, day habilitation, community living, and supported employment).
Respondents were asked how long they have worked in the rehabilitation field. Answers ranged from 2 years to 39 years, with a mean of 13.5 years of experience (SD 5 9.41). Participants were asked to describe the geographic location of their agency. Over half (51.8%) described their setting as rural. Provider agencies showed a wide range in the numbers of people served by the agency, from two to 1,100 (n 5 83, mean 5 107.3, SD 5 219.94). Agency services provided included: day habilitation (65.5%), residential (58.6%), community living support (58.6%), and supported employment (40.2%). Other provided services were: case management (32.2%), respite (23%), behavior supports (11.5%), and various therapies (4.6%). Agency directors were asked if anyone they served had expressed an interest in continuing their education. The majority did (70.1%). Those who answered ‘‘yes’’ were asked how many individuals whom they served wanted to continue their education. Responses ranged from one person to 55 people (n 5 61; mode 5 2). When taking agency size into account (i.e., dividing the number of individuals interested in pursuing their education by the total number of individuals served by that agency), individuals who indicated that they
Results The intent of this study was to explore the knowledge and attitudes of adult provider agencies. It also was intended to provide data that would serve as a foundation for further exploration of a key entity that brings particular attributes and strengths to the realm of PSE for individuals with ID. This is of special interest, given that there is not currently existing data that address the experiences of this study’s target population. Results are presented in two sections. The first section includes descriptive demographic characteristics of the Table 1 Basic Sample Characteristics Variable Years in field Age Served Gender Men Women Agency location Urban Suburban Rural Clients expressing interest in higher education Provider was involved in the transition process
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%
N
Mean
SD
86 87 87 86
14.4 44.3 119.4
9.61 11.28 219.94
16.3 83.7 85 27.1 21.2 51.8 70.1 33.3
61 29
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Table 2 Knowledge and Attitude Items Variable
N
Average Rank
SD
Individuals with ID can benefit from participating in higher education Provider agencies understand PSE is an option for individuals with ID I am aware of the reauthorization of the HEOA and what it means for individuals with ID Families understand that PSE is an option for individuals with ID Individuals with ID are unlikely to succeed in PSE
86 87 86
1.56 2.29 3.07
.64 1.09 1.02
87 87
3.09 3.75
1.01 .82
Note. ID 5 Intellectual disability; PSE 5 Postsecondary education; HEOA 5 Higher Education Opportunity Act. Rank: 1 5 strongly agree, 5 5 strongly disagree. wanted to continue their education represented a range of less than one percent up to 30% of those served by the agency. In fact, 21.8% of the directors responded that they served someone who was currently in college or technical school, with most having one person attending school (n 5 17; mode 5 1). Courses that were being taken included: general education and introductory level courses such as English and algebra, music composition, art, computer, public speaking, first aid, vocational automotive, and high school and GED (though the latter two do not fit with the definitions of college or technical school courses). One-third of respondents (33.3%) had helped a person with ID in the process of transitioning into college or a technical school. Agency directors were asked to rate their level of agreement on a series of statements related to PSE and people with ID. Responses were on a 5point Likert-type scale where 1 5 strongly agree, 2 5 agree, 3 5 neutral, 4 5 disagree, and 5 5 strongly disagree. Complete results can be found in Table 2. Respondents were most in agreement with the item ‘‘Individuals with intellectual disabilities can benefit from participating in higher education’’ (M 5 1.56, SD 5 .64). In fact, 92% of agency directors agreed or strongly agreed with this item. The lowest-ranked item was ‘‘Individuals with ID are unlikey to succeed in postsecondary education’’ (M 5 3.75, SD 5 .82). Additionally, although 69% of agency directors agreed or strongly agreed that their agencies understood PSE as an option for the persons they served, respondents agreed that only 34% of family members understood that PSE was an option. Agency directors indicated that a variety of resources would be helpful to increase their
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confidence in advising individuals with ID about continuing their education, with information on available supports (80.5%), funding (77%), and accessing PSE (72.4%) being the most needed. Respondents also indicated that, if they had a person interested in PSE, they would seek resources from a college or technical school disability support services office (74.7%) and the state office of vocational rehabilitation (70.1%).
Exploratory Analysis Because many agencies provided both day and residential services, further comparison between these groups was not completed. However, t-tests were conducted to determine if differences could be found between agencies that considered themselves rural or urban. No statistically significant differences were found on any items. As might be expected, a strong positive correlation was found between age and years worked in the field (r 5 .479, a 5 .01). No significant correlations were found between the number of years in the field and awareness items on this survey, suggesting that length of time working in the disability arena does not impact one’s knowledge of resources. However, age of respondent was moderately negatively correlated with the statement, ‘‘Realistically, individuals with intellectual disabilities are unlikely to succeed in postsecondary education’’ (r 5 2.381, a 5 .01). In other words, older respondents were more likely to have more positive expectations of people with ID in higher education. There was a strong correlation between provider agencies’ understanding of PSE and provider’s perception of the family understanding of PSE (r 5 .591, a 5 .01). There was also a strong
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correlation between family understanding of PSE and provider understanding of the HEOA and implications for people with ID (r 5 .474, a 5 .01). As would be expected, there was also a positive correlation between provider agency understanding of PSE and of provider understanding of the HEOA (p 5 .397, a 5 .01). These correlations are found in Table 3.
Discussion The results of this study show that adult service providers in one midwestern state have a great deal of interest in PSE for the adults with ID they serve. One finding was that those with a longer history working in the developmental disability field appear to more strongly agree that individuals with ID can benefit from higher education. This reemphasizes the need for additional training and resources to introduce the notion of PSE to providers. This includes addressing some of the common questions around entrance requirements and ability to access courses of interest when prerequisites stand in the way. This may be especially true for those professionals who have not been exposed to the idea of people with ID continuing on as learners into adulthood. Providers rated themselves as having a greater understanding of postsecondary opportunities for individuals with ID than they rated the understanding of family members in this area. Yet, given the integral role of families in supporting transition
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planning for youth with significant disabilities, as well as the role of parental expectations in shaping youth outcomes (Doren, Gau, & Lindstrom, 2012), knowledge of families about PSE at the point of transition is critical. We are at an important crossroads. There is dialogue taking place among stakeholders. Leadership within institutions of higher education is a vital component of fostering an environment that is welcoming of all learners. Secondary educators and families must have expectations that include higher education as a viable option for students and youth with ID. Individuals with ID must be motivated to continue their education beyond high school. Yet integral partners should also include providers of Medicaid waiver services who provide supports to young adults with ID once the secondary school career has concluded. These community-based providers must be included in the discussions to enhance their understanding of not only legislation and use of waiver funds to support students in higher education, but to recognize postsecondary education as a viable means of improving quality of life, through increased community connectedness, expanding social networks, elevated employment possibilities, and improved self-efficacy. The practice of including adult service provider agencies at the outset is an important factor in helping the student developing his or her college plans so that the planning includes time for classes, tutoring, extracurricular activities, volunteering,
Table 3 Knowledge and Attitude Correlates Measure
1
2
3
4
5
6
1. Individuals with ID can benefit from participating in 1 high education 2. Provider agencies understand PSE is an option for .12 1 individuals with ID 3. Families understand that PSE is an option for .11 .591* 1 individuals with ID 4. Individuals with ID are unlikely to succeed in PSE 2.37* 2.074 2.029 1 5. I am aware of the reauthorization of the HEOA and .065 .397* .47* 2.021 1 what is means for individuals with ID 6. Years in field 2.1 .02 2.02 2.21 2.15 1 7. Age .16 .02 2.05 2.37 2.18 .479*
7
1
Note. ID 5 Intellectual disability; PSE 5 Postsecondary education; HEOA 5 Higher Education Opportunity Act. *Significant at the .01 level.
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internships, and other facets of college life. Agencies that provide day and residential supports can also play a key role in navigating transportation issues. Indeed, a sense of belonging in the community of adult learners and an opportunity to pursue one’s goals and dreams are at the heart of PSE (CaustonTheoharis, Ashby, & DeClouette, 2009).
Limitations This study represented an exploratory survey in one state. Survey items were developed by an expert panel, composed of one state’s TPSID grant. Moreover, participants self-selected for this voluntary online survey. Although online surveys provide ease in development and distribution, the target population may not be responsive, particularly given the volume of online communications (Dillman, Smyth, & Christian, 2009). It is possible that those who did not respond had far different levels of knowledge or attitudes, though it is not likely that nonrespondents would have evidenced a greater awareness of PSE opportunities for students with ID than those who did respond. It is also possible that respondents answered the items in a way that they perceived as responding in the most socially appropriate way. Technology constraints of potential respondents may also have limited the response rate. This survey was also conducted approximately a month following an online provider training on higher education opportunities for students with intellectual disability in that state. Therefore, these results should be viewed with caution and as a snapshot in time, and may not be representative of adult service providers in other states. This study does serve, however, as a good starting point upon which to build further dialogue.
Implications for the Future The repository of knowledge related to PSE and ID is growing quickly. As of February 2014, nearly 30 CTPs have been approved, with many more in the application process. Although the offerings provided by these entities may vary by school, their overarching goal of providing a meaningful credential for students with ID is universal. This study provides an initial examination of perspectives of adult service providers. This set of stakeholders has a valuable perspective on the current service delivery system, along with insights into systemic issues that may either impede or promote successful transition into PSE. National and state-level
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resources must be made available to adult service provider agency personnel, so that they can be knowledgeable and supportive in conversations around higher education. Collaboration and a holistic approach to the provision of services for people with ID can best support the needs and wants of the whole person, including the opportunity to pursue PSE. We are encouraged that the vast majority of agency directors (92%) who responded to our survey believed that individuals with ID can benefit from participation in higher education. Further, 69% agreed that they had some understanding of PSE opportunities for individuals with ID, and that they perceived PSE as an important option for at least some of their clients. Awareness of this option and its potential benefits is a first step. The survey data presented here suggest the potential impact of dissemination and technical assistance efforts to maximize the involvement and understanding of adult services providers. Agencies can be provided with examples of adults with ID who are achieving success in PSE settings and, as a result, experiencing improved life outcomes. Information dissemination can also be used to demonstrate how the blending of separate funding streams, including Federal Pell Grants and Work-Study through university participation in a CTP, state vocational rehabilitation funds, Medicaid Waiver Services, and perhaps state scholarship funds provided to all students, can be ‘‘braided’’ through interagency agreements to create carefully crafted supports at the individual level. Adult service providers are valuable partners in the process for systems change in the area of higher education for people with ID. Training opportunities for these professionals may also result in increased awareness of PSE by families and individuals with ID. This survey found that providers rated families as considerably less knowledgeable of postsecondary educational options than the providers rated themselves. By training providers, and especially case managers, on the new possibilities available to adults with ID in PSE, the families of those served by the agency can also be ultimately impacted. Families and selfadvocates can provide powerful impetus for the further expansion of this endeavor. University Centers for Excellence in Developmental Disabilities (UCEDDs) can be valuable partners in this effort, along with Think College (www. ThinkCollege.net). The role of adult service providers will become increasingly important if
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we are to expand postsecondary educational opportunities for youth with ID and, ultimately, to enhance their life outcomes through PSE experiences, when that is the dream of the individual. This exploratory study is a small step in engaging adult providers in that essential conversation.
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Thoma, C. A., Lakin, C. K., Carlson, D., Domzal, C., Austin, K., & Boyd, K. (2011). Participation in postsecondary education for students with intellectual disabilities: A review of the literature 2001–2010. Journal of Postsecondary Education and Disability, 24(3), 175–191. Wagner, M., Newman, L., Cameto, R., Levine, P., & Garza, N. (2006). An overview of findings from wave 2 of the National Longitudinal Transition Study-2 (NLTS2) [NCSER 20063004]. Menlo Park, CA: SRI International. Retrieved from http://www.nlts2.org/reports/ 2006_08/nlts2_report_2006_08_complete.pdf Wolfensberger, W. (1972). The principle of normalization in human services. Toronto, Canada: National Institute on Mental Retardation. Yan, T., Kreuter, F., & Tourangeau, R. (2012). Evaluating survey questions: A comparison of methods. Journal of Official Statistics, 28(4), 503–529. Zafft, C., Hart, D. & Zimbrich, K. (2004). College career connection: A study of youth
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with intellectual disabilities and the impact of postsecondary education. Education and Training in Developmental Disabilities, 39(1), 45–53.
Received 2/4/2014, accepted 1/9/2015. Authors: Kathleen Sheppard-Jones and Harold Lawrence Kleinert, University of Kentucky, Human Development Institute; Wendy Druckemiller, Centerstone; and Megan Kovacevich Ray, Trilogy Behavioral Healthcare. Correspondence concerning this article should be addressed to Kathleen Sheppard-Jones, University of Kentucky, Human Development Institute, 210 Mineral Industries Bldg., Lexington, Kentucky 40506, USA (e-mail: [email protected]).
Provider Perspectives
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