Vocational rehabilitation services for African-American women with HIV/AIDS: An examination of acceptance rates and employment outcomes

Abstract

BACKGROUND:

Previous research identifies employment as a social determinant of health for persons with HIV/AIDS, specifically African American women.

OBJECTIVE:

The purpose of this study was twofold: (1) to examine the eligibility/acceptance and competitive employment rates of African American women diagnosed with HIV/AIDS in comparison to the general population of persons with disabilities in the state-federal vocational rehabilitation (VR) system and (2) to determine the relationship between (a) demographic variables (i.e., age, education level at the time of application for VR services, and receipt of cash benefit) and VR services received (e.g., job placement) and (b) employment outcomes for this population.

METHODS:

Chi square analysis was used to determine if there was a significant difference in acceptance/eligibility rate between the target population of African American women with HIV/AIDS and the general disability population. Multiple logistic regression analysis was used to determine the relationship between demographic variables and vocational rehabilitation services received on employment outcomes for the target population.

RESULTS:

Results indicate that the African American women with HIV/AIDS were found ineligible for services at a lower rate, 14%, than the general population of persons with disabilities served, 17%. However, even though they are more likely to be accepted for services, the competitive employment outcomes are lower than the general population of persons with disabilities. Results also indicate that the hypothesized demographic and VR service-related predictor variables were significantly related to competitive employment outcomes. Specifically, receipt of cash benefits and diagnostic /treatment VR services had a negative impact on employment outcomes. Factors positively associated with employment outcomes included receipt of job placement and maintenance services.

CONCLUSIONS:

Vocational rehabilitation counselors, researchers and other key stakeholders must identify the most effective strategies to assist African American women with HIV/AIDS in navigating the VR process from application to closure as competitively employed.

Keywords

African American women HIV/AIDS employment vocational rehabilitation rehabilitation counseling

1 Introduction

There has been a 42% decline in recent years in new diagnoses of the human immunodeficiency virus (HIV) among African American women (Centers for Disease Control and Prevention [CDC], 2016). However, this group remains disproportionately impacted compared to their other racial counterparts. According to the CDC (2016), estimates of HIV diagnoses among women in 2014 showed that 62% of those infected were African American, compared to 18% Whites and 16% Latinas, respectively. As individuals with HIV/AIDS continue to live longer and healthier lives, it is imperative that investigators shift focus to lifespan development and quality of life issues such as employment (Conyers, Chiu, Shamburger-Rousseau, Johnson, & Misrok, 2014; Musheke, Bond, & Merten, 2012).

Employment is an essential part of adulthood that fosters independence and self-direction while offering external rewards such as salary and healthcare benefits. However, poverty, discrimination, and social marginalization are powerful factors that have increased the challenges of persons with HIV/AIDS, especially for women and those representing marginalized racial and ethnic groups. Therefore, an essential element of the coordinated response to HIV/AIDS must include modes of addressing the spectrum of needs for this group including housing and employment in conjunction with prevention and healthcare access. The evolving national focus on HIV/AIDS policy, research, and service delivery is evidenced by the inclusion of the U.S. Department of Labor in the six lead Federal agencies responsible for implementing the National HIV/AIDS Strategy (NHAS) for the United States. The inclusion of employment and vocational services in the NHAS occurred in response to the critical role of these two factors in addressing continued health and quality of life of the target population (Office of Disability Employment Policy [ODEP], 2012). This strategy is in accordance with the Executive Order (July 15, 2013) of President Obama, which is the nation’s first-ever comprehensive plan for responding to HIV/AIDS. This trend is also reflected in the growing number of entities providing employment and training services to individuals with HIV/AIDS (e.g., National Working Positive Coalition). The 2013 executive order mandated enhanced support for employers to facilitate hiring and retaining of employees with HIV, as well as integrating them in broader employment initiatives.

There exists a small but convincing body of literature that documents the efficacy of vocational services and stable employment in improving quality of life, reducing levels of depression, enhancing HIV self-management, and decreasing HIV stigma and health risks associated with the condition (Conyers, 2004; Hunter, 2009; Rueda et al., 2011, 2012; Webel et al., 2013). However, a wide variety of factors hinder job placement and generate unstable employment opportunities for African Americans with HIV/AIDS. In particular, these individuals continue to experience limited access to the social support needed for effective career development and economic independence (Musheke, Bond, & Merten, 2012). The living and employment-related circumstances specific to African American women can be even more challenging.

Due to the intersection of gender, race and disability status, African American women with HIV/AIDS face harsher employment outcomes (Oberoi, Balcazar, Suarez-Balcazar, Langi, & Lukyanova, 2015) than do people with fewer disadvantaging characteristics. A systematic review evaluating the current literature on the daily experience of African American women with HIV/AIDS shows that these women experience significant levels of emotional distress, dehumanization, depression, and stigma (Petzler, Domian, & Teel, 2015). For those who experience severe emotional distress, such as depression or suicidal ideation, becoming employed has been shown to improve one’s psychological condition over time (Mascaro, Arnette, Santana, & Kaslow, 2007). For persons with HIV/AIDS, employment provides financial remuneration and meaning of life (Conyers, 2008); increases treatment adherence (International Labour Office, 2013); and enhances community integration and overall quality of life over time. Though the effect of active participation in the labor force can be immensely positive, job loss may result in a drastic and dangerous decline in health status, especially among those with generalized poor pre-employment well-being.

Literature reveals that women, African-Americans, and people with HIV/AIDS have poorer employment outcomes compared to the general population (Bureau of Labor Statistics [BLS], 2016; Dray-Spira et al., 2006). HIV-related stigma has been linked to lower employment outcomes (Pager, Western, & Sugie, 2009). Race is another barrier to employment for African Americans due to intentional and unintentional discrimination, lower socioeconomic status, and limited social upward mobility (Dau-Schmidt & Sherman, 2013). In addition, African-Americans have less access to state-federal vocational rehabilitation services that assist clients in obtaining and maintaining employment (Conyers et al., 2014; Kim-Rupnow, Park, & Starbuck, 2005). Even when seeking assistance for state-federal vocational rehabilitation services, aggregate data show that African American women, particularly younger ones, have lower odds of achieving employment compared to their White counterparts (Oberoi, Balcazar, Suarez-Balcazar, Langi, & Lukyanova, 2015). The emerging literature on the beneficial impact of stable employment on health and quality of life for African American women with HIV/AIDS serves as an impetus for developing innovative vocational interventions to address the social and cultural vulnerability of the target population (Conyers et al., 2014).

The state-federal vocational rehabilitation (VR) program is a major public resource that can assist African American women with HIV/AIDS in achieving improved employment outcomes. However, a critical analysis of the most recent data from the state-federal VR program is necessary to determine the impact of service provision on employment related outcomes. Consequently, the aim of this study was to investigate the level of access African American women with HIV/AIDS have to the VR system. Specifically, we investigated the relationship between demographic variables, state-federal vocational rehabilitation services, and employment outcomes for this population. The following two research questions were addressed.

Is there any significant difference in eligibility/acceptance rates between African American women diagnosed with HIV/AIDS and the general population of persons with disabilities served by state-federal VR agencies?

What is the relationship between demographic variables, VR services received, and employment outcomes for African American women diagnosed with HIV/AIDS?

2 Method

2.1 Data source and participants

Data for this ex-post facto study were retrieved from the Rehabilitation Services Administration (RSA) 911 database for fiscal years 2010 through 2013, the most recent released RSA-911 datasets. RSA-911 is one of the largest disability-related databases in the nation, and it uses a reporting system to collect demographic and VR service-related information from clients who received VR services. Coding procedures used to conduct analyses in this study were in congruence with guidelines established by RSA.

After deleting cases with missing data, RSA-911 data for analysis included 2,371,024 clients whose VR cases were closed during the four-year observation period (2010–2013). Seven hundred forty-three of the clients were African American women with HIV/AIDS. The primary dataset for analysis included this sample. At the time they had enrolled in the VR program, the mean age of participants was 42.76 (SD = 9.12). The largest proportion of the participants were high school graduates (40.5%), 31.2% had associate’s degrees, 24.1% had less than high school education, 3.4% had bachelor’s degrees or higher, and 0.8% had been special education students. Ninety-nine percent of the participants indicated that they had significant disabilities and 56.7% were recipients of Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) cash benefits.

2.2 Dependent variables

First, the eligibility/acceptance rate of African American women with HIV/AIDS was compared with the rest of the VR clients whose cases had been closed during the 2010–2013 observation period. The eligibility/acceptance rate was coded using the following categories.

Exited as an applicant (Line D7 on RSA-113)

Exited during or after a trial work experience/extended evaluation (Line D6 on RSA-113)

Exited with a successful competitive employment outcome (Line D1 on RSA-113)

Exited without an employment outcome, after receiving services (Line D2 on RSA-113)

Exited without an employment outcome, after a signed Individualized Plan for Employment (IPE), but before receiving services (Line D4 on RSA-113)

Exited from an order of selection waiting list (Line D5 on RSA-113)

Exited without an employment outcome, after eligibility, but before an IPE was signed (Line D3 on RSA-113)

In this study, clients who exited the state-federal VR program based on the following eligibility/application statuses were recoded as application not accepted/ineligible for services: exited as an applicant (status 02 or 08), exited during or after a trial work experience or extended evaluation (status 06 or 08), or exited from an order of selection waiting list (status 04 or 38). Clients who exited as successfully employed (status 26), exited after determined eligible but before IPE completed (status 30), or exited not-employed after signing IPE or receiving services (status 28), were coded as application accepted/ eligible for services.

Next, factors affecting the successful competitive employment rate of African American women with HIV/AIDS were examined. RSA defines competitive employment as working either full-time or part-time in an integrated setting, self-employment, or in a Business Enterprise Program for a minimum wage or higher for at least 90 days. Minimum wage is the state or federal minimum wage, whichever is higher. If a client was not employed in an integrated setting after receiving VR services and completing the program, the case was considered to have an unsuccessful outcome.

2.3 Independent variables

To investigate whether being an African American woman with HIV/AIDS would be related to acceptance/eligibility rate in the VR system, data were recoded as African American women with HIV/AIDS versus other applicant as the first independent variable. To investigate competitive employment rates for African American women with HIV, two sets of independent variables were used. The first set of independent variables included age, education level at the time of application for VR services, and receipt of cash benefits. Cash benefits refer to receipt of SSI or SSDI benefits from the Social Security Administration. The second set of independent variables was the VR services that African American women with HIV/AIDS received. These services are described in Table 1.

Table 1
Description of vocational rehabilitation services

Types of Services Descriptions of Services

1. Assessment Services provided and activities performed to determine an individual’s eligibility for vocational rehabilitation services, to assign an individual to a priority category of a state vocational rehabilitation agency that operates under an order of selection, and/or to determine the nature and scope of vocational rehabilitation services to be included in the Individual Plan for Employment (IPE); included in this category are trial work experiences and extended evaluation.

2. Diagnosis and Treatment of Impairments Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and emotional disorders.

3. 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.

4. 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 four-year college or university, community college, junior college, or technical college.

5. 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.

6. 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.

7. 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.

8. Job Readiness Training Training to prepare an individual for the world of work (e.g., appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity).

9. Disability-Related, Augmentative Skills Training Service 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.

10. Miscellaneous Training Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.

11. 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, and developing interview skills, and may include making contacts with companies on behalf of the consumer.

12. Job Placement Assistance A referral to a specific job resulting in an interview, whether or not the individual obtained the job.

13. 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 follow-along, and job retention services.

14. Transportation Services Travel and related expenses necessary to enable an applicant or eligible individual to participate in a vocational rehabilitation service; includes adequate training in the use of public transportation vehicles and systems.

15. Maintenance Services Maintenance means monetary support provided for those 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 and vocational rehabilitation needs or while receiving services under an individualized plan for employment (IPE).

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. Information and Referral Services Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the vocational rehabilitation program.

22. Other Services All other vocational rehabilitation 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.

Types of Services	Descriptions of Services
1. Assessment	Services provided and activities performed to determine an individual’s eligibility for vocational rehabilitation services, to assign an individual to a priority category of a state vocational rehabilitation agency that operates under an order of selection, and/or to determine the nature and scope of vocational rehabilitation services to be included in the Individual Plan for Employment (IPE); included in this category are trial work experiences and extended evaluation.
2. Diagnosis and Treatment of Impairments	Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and emotional disorders.
3. 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.
4. 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 four-year college or university, community college, junior college, or technical college.
5. 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.
6. 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.
7. 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.
8. Job Readiness Training	Training to prepare an individual for the world of work (e.g., appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity).
9. Disability-Related, Augmentative Skills Training	Service 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.
10. Miscellaneous Training	Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.
11. 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, and developing interview skills, and may include making contacts with companies on behalf of the consumer.
12. Job Placement Assistance	A referral to a specific job resulting in an interview, whether or not the individual obtained the job.
13. 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 follow-along, and job retention services.
14. Transportation Services	Travel and related expenses necessary to enable an applicant or eligible individual to participate in a vocational rehabilitation service; includes adequate training in the use of public transportation vehicles and systems.
15. Maintenance Services	Maintenance means monetary support provided for those 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 and vocational rehabilitation needs or while receiving services under an individualized plan for employment (IPE).
16. 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.
17. 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.
18. 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.
19. 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.
20. 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.
21. Information and Referral Services	Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the vocational rehabilitation program.
22. Other Services	All other vocational rehabilitation 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.

2.4 Data analysis

Chi-square tests of independence and a multivariate multiple logistic regression analysis were used to answer the first and second research questions, respectively. The Chi-Square test of Independence, a non-parametric tool, examines if there is a statistically significant difference between two nominal (categorical) variables. The frequency of one nominal variable is compared with different values of the second nominal variable. This analytical tool ascertains if there is an actual proportional difference between those variables or if the observed proportional difference is due to sampling errors. Contingency tables are used to show percentages and counts of those variables.

Multivariate multiple logistic regression analysis was performed to investigate factors influencing the likelihood of competitive employment outcomes for African American women with HIV/AIDS. Hosmer, Lemeshow, and Sturdivant (2013) suggested using “purposeful selection” between the predictor variables in logistic regression analysis because it produces the most parsimonious and “best-fit” model. Their 7-step purposeful selection method includes:

Identifying variables that have one-on-one significant relationships with the outcome variable using an α level of 0.20 or 0.25 to recruit important predictor variables.

Entering all variables that were found to have a significant relationship with competitive employment at step 1 using the “enter” method.

Retaining variables that were significant using an α level of.05; and removing variables that were not significant when removal of them did not change the β coefficients of the significant variables by more than 20%.

Entering variables that were not significant at step 1 into the regression model one at a time and retaining them if they turned out to be significant.

Critically examining the variables and changes in the model.

Checking interactions between the variables in the model.

Assessing adequacy of the model and checking the model’s fit.

3 Results

A crosstab was formulated to determine if there was a significant difference in acceptance/eligibility rates between African American women with HIV/AIDS and the rest of the VR client population. The results indicated that there was a significant difference: African American women with HIV/AIDS had significantly lower rejection rates than did the rest of the VR clients, X²(1, 2371024) = 6.200, p < 0.01. The ineligibility/rejection rate for African American women with HIV/AIDS was 14% versus 17% for other clients. However, when reasons for case closure and competitive employment outcome rates were examined, the results indicated that there was a significant difference, X²(14, 2371024) = 110.303, p < 0.01 between African American women with HIV/AIDS and other clients. Despite the fact that African American women with HIV/AIDS had lower rejection rates in the VR system, they also had lower case closure rates (19.4%) than other VR clients (30.1%). In addition, African American women with HIV/AIDS had lower rates of service refusal (15.5% versus 17.2%), higher rates of refusal to cooperate (23.8% versus 14.3%), and higher rates of unable to locate (24% to 19.5%) than did the rest of the VR population.

Table 2 presents the frequencies of VR services received by members of the study sample across age groupings. To investigate the relationships between (a) demographic variables and VR services and (b) employment outcomes for African American women with HIV/AIDS, a multiple logistic regression analysis utilizing the purposeful selection method was employed. The results showed that, after completing VR services, more than half of the African American women with HIV/AIDS did not achieve competitive employment (61.8%). On average, these clients were provided 4.08 (SD = 4.00) services, stayed in the VR program for 29.44 (SD = 22.80) months, and utilized services at a median case expenditure of $2,098 (SD = $4,765).

Table 2
Frequencies and percentages of services received by age group

16–34 years old 35–54 years old 55–64 years old

N (%) N (%) N (%)

1   Assessment 88 (63.8%) 325(59.5%) 31(52.5%)

2   Diagnosis and Treatment of Impairments 44 (31.9%) 174(31.9%) 23(39.0%)

3   Vocational Rehabilitation Counseling 87 (63.0%) 307(56.2%) 26(44.1%)

4   College or University Training 29 (21%) 64(11.7%) 8(13.6%)

5   Occupational/Vocational Training 22 (15.9%) 117(21.4%) 6(10.2%)

6   On-the-Job Training 2 (1.4%) 11(2.0%) 0(0%)

7   Basic Academic Remedial training 1(0.7%) 6(1.1%) 0(0%)

8   Job Readiness Training 18(13%) 84(15.4%) 89(13.6%)

9   Augmentative Skills Training 5 (3.6%) 10(1.8%) 1(1.7%)

10   Miscellaneous Training 16 (11.6%) 77(14.1%) 13(22%)

11   Job Search Assistance 26(18.8%) 121(22.2%) 10(16.9%)

12   Job Placement Assistance 42(30.4%) 215(39.4%) 21(35.6%)

13   On-the-Job Supports 15(10.9%) 49(9.0%) 7(11.9%)

14   Transportation Services 65(47.1%) 289(52.9%) 37(62.7%)

15   Maintenance Services 29(21.0%) 93(17.0%) 8(13.6%)

16   Rehabilitation Technology 4(2.9%) 23(4.2%) 3(5.1%)

17   Reader Services 0(0%) 2(0.4%) 0(0%)

18   Interpreter Services 0(0%) 2(0.4%) 0(0%)

19   Personal Attendant Services 0(0%) 0(0%) 0(0%)

20   Technical Assistance Services 0(0%) 3(0.5%) 0(0%)

21   Information and Referral Services 14(10.1%) 69(12.6%) 4(6.8%)

22   Other Services 39(28.3%) 191(35.0%) 15(25.4%)

		16–34 years old	35–54 years old	55–64 years old
1	Assessment	88 (63.8%)	325(59.5%)	31(52.5%)
2	Diagnosis and Treatment of Impairments	44 (31.9%)	174(31.9%)	23(39.0%)
3	Vocational Rehabilitation Counseling	87 (63.0%)	307(56.2%)	26(44.1%)
4	College or University Training	29 (21%)	64(11.7%)	8(13.6%)
5	Occupational/Vocational Training	22 (15.9%)	117(21.4%)	6(10.2%)
6	On-the-Job Training	2 (1.4%)	11(2.0%)	0(0%)
7	Basic Academic Remedial training	1(0.7%)	6(1.1%)	0(0%)
8	Job Readiness Training	18(13%)	84(15.4%)	89(13.6%)
9	Augmentative Skills Training	5 (3.6%)	10(1.8%)	1(1.7%)
10	Miscellaneous Training	16 (11.6%)	77(14.1%)	13(22%)
11	Job Search Assistance	26(18.8%)	121(22.2%)	10(16.9%)
12	Job Placement Assistance	42(30.4%)	215(39.4%)	21(35.6%)
13	On-the-Job Supports	15(10.9%)	49(9.0%)	7(11.9%)
14	Transportation Services	65(47.1%)	289(52.9%)	37(62.7%)
15	Maintenance Services	29(21.0%)	93(17.0%)	8(13.6%)
16	Rehabilitation Technology	4(2.9%)	23(4.2%)	3(5.1%)
17	Reader Services	0(0%)	2(0.4%)	0(0%)
18	Interpreter Services	0(0%)	2(0.4%)	0(0%)
19	Personal Attendant Services	0(0%)	0(0%)	0(0%)
20	Technical Assistance Services	0(0%)	3(0.5%)	0(0%)
21	Information and Referral Services	14(10.1%)	69(12.6%)	4(6.8%)
22	Other Services	39(28.3%)	191(35.0%)	15(25.4%)

The mean number of services provided to clients who achieved competitive employment (M = 4.37, SD = 2.20) was significantly higher than that for those who had unsuccessful outcomes (M = 3.89, SD = 2.10; t(673) = –2.84, p < 0.001; d = –0.21). The median cost of those services was also higher for clients who achieved competitive employment ($2829, SD = $5907 versus $1624, SD = $3820). Clients who achieved competitive employment spent significantly less time in VR services (M = 23.50, SD = 18.71) than those who had unsuccessful outcomes (M = 33.12, SD = 23.84; t(636) = 5.83, p < 0.01, equal variances not assumed d = 0.46).

The results also revealed that assessment (60.0%), vocational rehabilitation counseling and guidance (55.6%), and transportation (53.0%) were the three most frequently provided services. Less than 1% of the clients were provided technical assistance, personal attendant services, interpreters, reader, and basic academic remedial or literacy training services. Therefore, those services were not used in the regression analysis.

3.1 Multiple logistic regression analysis

In order to determine the relationship between (a) client demographic characteristics and (b) competitive employment outcomes for African American women with HIV, a multiple logistic regression analysis was performed. The predictor variables included in the regression model were age at application (i.e., 16–34, 35–54, 55–64; 16–34 years was the reference category); education level at application (i.e., special education, less than high school, high school graduate, associate’s degree, bachelor’s degree or higher; bachelor’s degree or higher was the reference category); receiving disability benefits (i.e., receiving SSI/SSDI, not receiving SSI/SSDI; not receiving SSI/SSDI was the reference category); and VR services received.

In the first step of the analysis, cash benefits, diagnosis and treatment, occupational/vocational training, on-the-job training, disability related augmentative skills training, job search assistance, job placement, on-the-job support, and maintenance services had a significant relationship with the competitive employment criterion at the p < 0.20 level. In the second step, in the presence of other predictor variables, cash benefits, diagnosis and treatment, job placement, and maintenance were associated with competitive employment. The variables that were not significant (occupational/vocational training, on-the-job training, disability related augmentative skills training, job search assistance, and on-the-job support) were dropped one by one. Removal of those variables did not change the β level of any of the significant variables by more than 20%. Next, the client demographic and VR service variables that were not significant in the first step (age, education level, assessment, vocational rehabilitation counseling and guidance, college or university training, job readiness training, miscellaneous training, transportation services, rehabilitation technology, information-referral and other services) were entered into the model one-by-one. None of those variables yielded significant results.

As for the final model, the omnibus test was significant (χ²(4, N = 675) = 54.90, p < 0.001), indicating that the predictor variables were significantly related with the competitive employment outcome variable. The Nagelkerke R² of 0.10 indicated that predictors had a small to moderate effect on the outcome variable. The Hosmer and Lemeshow test χ²(6, N = 675) = 3.13, p = 0.79) indicated that there was a fit between the model and the data (Kleinbaum & Klien, 2010).

Specifically, clients who did not receive cash benefits were more likely to obtain competitive employment (OR = 0.58; 95% CI: 0.41–0.80) than clients who received cash benefits. The odds ratios for the VR services as predictor variables were as follows:

The odds of clients who received job placement services obtaining competitive employment were 2.71 times (OR = 2.71; 95% CI: 1.95–3.78) greater than the odds of those who did not receive job placement services.

The odds of clients who received maintenance services obtaining competitive employment were 1.70 times (OR = 1.70; 95% CI: 1.11–2.59) greater than the odds of those who did not receive maintenance services.

Participants who received diagnosis and treatment services had a 35% reduction in the odds of obtaining competitive employment (OR = 0.65; 95% CI: 0.46–0.93) compared to clients who did not receive diagnosis and treatment services.

4 Discussion

The current study has several limitations that may affect interpretation and generalizability of the results. First and foremost, this study used archival data that did not allow researchers to manipulate the independent variables. Therefore, the findings can only indicate correlational, statistical relationships between the variables; causal relationships cannot be inferred. Second, in light of possible differences in service provision between and within state VR agencies, readers should exercise caution in generalizing these national-level results to specific states. Third, although VR counselors use an 18-point cross check for accuracy of data entry, they may have made recording errors that reduce the accuracy of the results.

Despite these limitations, findings from this study yield potentially important implications. The first part of the study tested whether there was a significant difference in eligibility/acceptance rates between African American women with HIV/AIDS and other VR clients of both genders. Results showed that African American women with HIV/AIDS were more likely to be deemed eligible and accepted for vocational rehabilitation services. As eligibility for vocational rehabilitation services is based on strict criteria of functional limitations that may impede job placement (Rubin, Roessler, & Rumrill, 2016), the above finding emphasizes that African American women with HIV/AIDS have both significant disability-related limitations to their employment prospects and significant potential for employment success. It was also found that African American women with HIV/AIDS had lower rates of and poorer quality of competitive employment outcomes as compared to other clients. Proportionally more cases involving African American women with HIV/AIDS were closed due to “refused to cooperate” and “unable to locate,” which may be linked to experiences with poverty (e.g., no phone or stable address) and/or cultural mistrust of government agencies and service providers. Earlier research on VR outcomes for African Americans indicated that cultural differences and mistrust of the state-federal system may lead to higher rates of unsuccessful case closures (Alston, 2003). Additionally, African American women with HIV/AIDS may encounter considerable challenges secondary to their co-existing chronic illness and low socio-economic status. Therefore, VR counselors need to be sensitive to the individualized, culture-specific, and gender-influenced needs of African American women with HIV/AIDS during service planning and provision (Gray, 2002). Multicultural education/training and outreach programs for VR counselors and related professionals could have a positive influence on the quality of services provided to and outcomes achieved by members of this study’s target population.

The second part of the study identified predictors of competitive employment outcomes for African American women diagnosed with HIV/AIDS. Results underscored the importance of job placement services such as identifying job leads, résumé preparation, and helping clients set up job interviews as vehicles to competitive employment. This finding aligns with that of Dutta, Gervey, Chan, Chou, & Ditchman (2008), which indicated that job placement services were significantly associated with competitive employment for people with physical disabilities. Furthermore, Pete et al. (2015) found a similar link between job placement services and competitive employment for African American VR clients with various disabilities. However, the current study found that only a small percentage of African Americans with HIV/AIDS (0.9% to 19.5%) were provided job preparation services. African American women with HIV/AIDS might need additional support to establish initial contact with employers and to set up job interviews. It is possible that African American women with HIV/AIDS might feel less-stigma when VR counselors refer them to an employer and act as a bridge between the employer and the client. Furthermore, African-American women might not have access to available job options and need more support to find jobs that match with their abilities and interests. When these placement-related services are provided, results of this investigation clearly indicate an increase the person’s likelihood of competitive employment.

This study further indicated that maintenance services including identifying, accessing, and utilizing all possible sources of monetary support were significantly associated with competitive employment. This finding aligns with Kaya et al. (2016), who reported that maintenance services were significantly associated with competitive employment for African-American youth with disabilities. Due to high rates of poverty, African American women with HIV/AIDS may need extra monetary support to cover important job related expenses (e.g., uniforms, public transportation, child care) to obtain and retain competitive employment. Therefore, VR counselors need to collaborate with various support programs to make sure that these clients receive long-term support services that help them to seek, achieve, maintain, and make progress in competitive employment.

Results also indicated that the receipt of cash benefits was negatively associated with competitive employment. This finding, although of low effect size, has been consistently reported in literature regarding VR outcomes for Americans with disabilities (e.g., Dutta et al., 2008; Kaya et al., 2016), and it suggests that disincentives in the Social Security Administration’s disability benefits programs may pose strong barriers to employment for this study’s target population. Research shows that, although people with disabilities want to work, they are often afraid of losing their SSI or SSDI benefits (O’Day & Revell, 2007), particularly health insurance benefits through Medicaid or Medicare. This is especially relevant to members of the present study’s sample, as people living with HIV/AIDS must have individualized medical treatment to effectively manage their chronic illness. Effective and culturally-sensitive benefits counseling should be provided or administered by VR agencies, because review and explanation of benefits can reduce the intensity of these types of concerns (Nazarov, 2013). Gender-responsive VR services also need to be tailored to the appropriate phase of work that is under consideration so that prevailing medical, psychosocial, financial/legal, and vocational factors impeding achievement of social and economic empowerment can be removed or reduced (Conyers et al., 2014).

Finally, results indicated that receipt of more services at a higher level of expenditure over a shorter time span may have a positive effect on the motivation of African American women with HIV/AIDS to obtain competitive employment. Receipt of intensive, time-limited services may generate feelings of empowerment and confidence and aid job placement efforts and outcomes in this population of women (Fabianova, 2011).

5 Conclusion

Findings from this study add to the literature on employment outcomes for African American women with HIV/AIDS, one of the most marginalized consumer groups in the United States. It is clear that this clientele is deemed eligible for services at a higher rate than the general population of persons served by VR agencies. However, they receive fewer evidence-based services than other VR clients, services that could aid them significantly in achieving higher rates of employment success following completion of VR services. Once a client is deemed eligible for services, VR counselors should use culturally-sensitive strategies to keep this vulnerable population engaged in all stages of the process. Addressing barriers such as cultural mistrust early on in the process by establishing a collaborative, therapeutic working alliance is critical to helping members of the target population plan for and achieve their goals of employment and overall self-sufficiency. As the seminal research of Conyers et al. (2014) has identified employment as a social determinant of health for persons with HIV/AIDS, it is important that VR counselors take appropriate steps to ensure that African American women diagnosed with HIV/AIDS matriculate through the process successfully. Lastly, in view of the continued employment related challenges encountered by members of the target population, it is imperative that research endeavors focus on the following aspects: (a) investigation of the effects of various factors on social and economic experiences secondary to their health statuses and racial, gender, and social class locations; (b) modalities used by African American women with HIV/AIDS to formulate, sustain, and interweave their economic survival strategies and psychosocial relationships; and (c) job placement strategies that incorporate the employer, client, providers, and contextual factors into employment goal persistence and outcome expectation among members of the target population.

Authors’ note

The ideas, opinions, and conclusions included in this article are those of the authors and do not represent recommendations, endorsements, or policies of the U.S. Department of Education.

Conflict of interest

The authors(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The contents of this article were developed with support from the Vocational Rehabilitation Technical Assistance Center for Targeted Communities (VR TAC TC: Project E3) at the Department of Rehabilitation and Disability Studies, Southern University, Baton Rouge, LA funded by the U.S. Department of Education, Rehabilitation Services Administration (Grant# H264F15003).

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