SEPTEMBER 23, 2009 VCU WEBCAST Services Provided By: Caption First, Inc. >> ALLEN LEWIS: Greetings. I am Allen Lewis of the Virginia Commonwealth University department of rehabilitation counseling in the school of allied health professions in Richmond, Virginia in the United States of America. Welcome to our Webcast on disability disparities. Please allow me to start things off today with a round of thanks to all who made this project and the Webcast today possible. First we would like to thank the National Institute of Disability and Rehabilitation Research, and specifically our project officers, Delores Watkins, project empowerment grant team at Virginia Commonwealth University which includes a cast of thousands, as well as the Southwest Educational Development Laboratory, also known as SEDL, based at the University of Texas in Austin. Our mission today is to talk about a concept called health disparities or disability disparities. I will provide background in the way of introduction, present a model I've proposed, and at the end we will begin to discuss how to address disability disparities in terms of key strategies. In our discussion today we are fortunate to have a panel of experts. We have Andrew Imparato, the CEO of the American Association of People With Disabilities. It's the largest cross-disciplinary voice for persons with disabilities in the United States. We also have Keith Wilson, professor at Penn State University and one of the seminal researchers in the realm of disability and culture; and Philip Rumrill, professor at Kent State University, one of the most prolific researchers generally speaking in the field of rehabilitation today. Our time today is brief, so let's get started. The concept of health disparities is well-documented in the field of healthcare. The Institute of Medicine arguably offers the predominant definition of health disparity today. The Institute of Medicine says a health disparity is a differential outcome attributed primarily to one's race or ethnicity. This difference is apparent even when factors such as social economic status and access to care are eliminated as possible contributors to uneven outcomes. Health disparities are a personal interest of mine, and I became very curious about them, particularly their relationship to the link between disability and culture. As a rehabilitation counselor, of course, we deal more with disabilities than we do with general health issues. As I began to search the literature for a disability model, I didn't find one. However, section 21 of the Rehab Act amendment of 1992, though not a model, comes closest to specifying the disability disparities concept. Section 21 provides much of the legislative impetus for the public rehab and disability system to strive to do a better job in serving culturally diverse populations. Section 21 posits that ethnically diverse populations in state -federal system typically have higher incidence of disability, lower levels of participation when they access the formal system, and fewer successful outcomes at the end of the rehabilitation process. Given the lack of an explicit model in the rehabilitation literature that addresses disability disparities, my goal has been to begin to develop a definition and a beginning model to help specify this phenomenon conceptually. One of the things that immediately became apparent to me was that the concept of cultural competency and disability disparity are linked. Disability disparity are the problem cultural competence attempts to eliminate. In the absence of disability disparities, one of cultural competency's primary reasons for being is eliminated. Cultural competency includes an awareness of own assumptions, biases and limitations when working cross-culturally, and the understanding of the world view of other persons who are different from one's self, culturally different, without imposing negative judgments, and the ability to practice appropriately with culturally different clients. Professor Wilson, Dr. Wilson, if you would, sir, help us understand, if you can, the link between cultural competency and disability disparities. >> KEITH WILSON: Yes, be glad to. Disability disparities and cultural competency might be connected in several ways, and looking at of course both the quantitative and qualitative research which suggests that racial minorities with disabilities tend to be underserved and have outcomes that are not favorable when compared to Americans and I'm speaking optically here. I think another concern would be that this is not surprising, given that our VR system, if you will, is a microcosm of society, meaning that VR counselors, for example, are no better at being less sexist, less racist, less homophobic in general, as our general society. Of course, folks bring these kinds of attitudes into work with them. It's very difficult to leave these attitudes at the door, which some folks would suggest that we should try to do, but is kind of impossible to leave these attitudes at the door. I think something I do want to add, cultural competencies, I think in many of the training that folks undergo, there are two levels I think of cultural competencies folks are trying to address. One is cognitive. I think that predominates the disability multicultural training literature, which means that individuals do understand that folks with disabilities who may be racially and ethnically diverse are different on certain traits. But I think one of the things that we do less of is looking at the behavior changes that folks would hopefully like to employ, once they have this cognitive information. >> ALLEN LEWIS: Thank you. Would you agree there is that link between cultural competencies and disability disparity? >> KEITH WILSON: I would agree definitely. >> ALLEN LEWIS: We are talking about the concept called cultural competency. But if you read in the literature nowadays, you will see some other terms that are the new generation versions of that concept, cultural efficacy or humility. For folks who are up on the literature and who may frown at the fact we are using the term cultural competency, we recognize it's a somewhat dated term. We want to use it because it's a term most folks associate these days with – >> KEITH WILSON: Yes. >> ALLEN LEWIS: Thank you. There is also a business argument that underscores the value of working to eliminate disability disparities through enhanced cultural competency of the disability system. This business argument offers that publicly funded disability and rehabilitation programs face high pressure and accountability these days that takes the form of four primary aspects: One, limited and uncertain funding; two, or B, increasing demands for services; C, consumers insist upon services meeting their needs, and that is a good thing; and 4, or D, the expectation imposed by taxpayers that government bodies extend public resources responsibly to maximize the reach of those dollars. Attorney Imparato, would you tell us some other ways that the public rehabilitation and disability system faces accountability demands here in the 21st century? >> ANDREW IMPARATO: Sure. I think the basic challenge that all government service agencies are facing is, with a difficult economic climate, and a shrinking tax base, and an aging population that is going to be requiring more and more from government as they get older, we are going to be competing and we are competing at the state level and the national level for scarce resources in the budget. I think the field of vocational rehabilitation and service delivery to people with disabilities more broadly is going to experience more and more pressure to show what the cost/benefit analysis is if the government spends money in this area, what is the benefit to the taxpayers and to the government and to the intended beneficiaries of the money. And if vocational rehabilitation cannot point to long-term employment outcomes, at an increased quality of life for increased human capital for people who are served by vocational rehabilitation, they are going to have a harder time making a business case and political case for their budget and certainly for increases in their budget. So, to me, cultural competency or cultural humility and this issue of disability disparity is part of making a business case. There are a lot of members of congress, there is lots of states' legislators who are going to want to know, how is public vocational rehabilitation doing in meeting the needs of people with disabilities from diverse racial and ethnic backgrounds? And if they are not doing well, they want to know what is the strategy to address those disparities within the field of rehabilitation itself. >> ALLEN LEWIS: Thank you very much, attorney Imparato. Very well spoken. I would say, chime in that clearly there seems like there is a mandate to do more in the 21st century, which means that we cannot afford to not be affected with all populations which here again make the point we have to be more cost (indecipherable) have more humility as we go forward to eliminate disparities. Let's talk about the working definition that I'm offering as well as the model of disability disparity as we move along. A disability disparity in my opinion exists when an underserved ethnic or racial minority cultural group's goal is to receive services within the formal rehabilitation and disability system, be it public or private, but there is a differential experience based primarily on cultural orientation that results in higher incidence of disability and/or lower representation in the formal helping system in terms of participation and fewer successful individual outcomes when compared to the majority group cultures. Note that this working definition builds quite substantially on section 21 of the Rehabilitation Act of 1992. Those amendments include the factors of high incidence of disability, lower participation in services and fewer successful outcomes of services. This definition clearly builds upon or was acknowledged in the 1992 set of amendments in section 21 of the Rehab Act. Dr. Phil Rumrill, would you tell us a little bit about, or give us an impression if you would, sir, of this definition that we are positing at this point of disability disparities; how does that strike you as a person who has been in the rehabilitation field for many years and done research for a number of things? >> PHILIP RUMRILL: Thank you, Allen. There is a number of things that really strike me right from the very beginning. I think that it is true that really the rehabilitation process, as legislation has been articulated into direct service and rehabilitation practice, has always had threaded through it an emphasis on providing responsive and quality services to people based on need, and in fact, prioritizing services in favor of people who have the greatest needs for a particular service, or having the most difficulties with any particular outcome. That hasn't always been based on racial and/or ethnic difference. But it strikes me that we have needed to account for those kinds of things a long time. We prioritize services for people with the most severe disabilities, for example, in the state vocational rehabilitation program. We set up separate systems and programs for people with certain types of disabilities, so that we can most effectively and accurately meet their unique needs. Yet at the same time, people who, for those purposes, disability becomes the primary differentiating feature, disability or not, or type of disability versus another one, but even within taking disability in the broadest aggregate, then we have to look at populations within the disability community, if you will, who are receiving less and more attention and experiencing better and worse outcomes. I'm glad that my colleagues here on the panel, and they both know better than I do about this, in the broad kind of macro sense, and we are talking about groups of people who on one hand, this is the other part of the model that is interesting, you have got groups of people who on one hand have a higher incidence of disability, so therefore, they have a greater need just by definition, but then they also experience the fewer positive outcomes. So you have more people with greater needs, experiencing poorer and poorer outcomes. So we have really got double the reason to understand this and intervene. And I think the link here coming out to the cultural competence or efficacy or humility of the counselor plays a big part, as I think about my own role in training rehabilitation counselors, in thinking about how this articulates to direct service. I think there is a lot of really interesting things here, just from a heuristic standpoint. But it really has a lot of practical significance too, and when you place it in historical context of how our field has been structured and organized, really relevant, and probably a specificity that we have been needing for decades. >> ALLEN LEWIS: Thank you, Dr. Rumrill, thank you a lot. Okay. With that, we are going to move into a full description of the model that has been proposed. One thing I'll tell you at the outset, the model is a beginning model in my mind. It's at least a starting point in the discussion. It is fairly broad. It is conceptual and hopefully has explanatory power. At first glance it can look fairly complex. But I can assure you that it's not as complex as it looks. I'll try to orient you to all that is there, and we will walk through the various aspects to see what is actually depicted in the visual. Okay. That is the model. All right. So, what I'm going to do is walk you through, first of all, left to right horizontally, into the model, and down each of the five domains. The first thing you notice when you look at the visual in the model is that there is a definition, that working definition that I propose at the very top. Just below that, on the next horizontal line below that, you will see five domains that appear across. Each domain represents a point on a five-point continuum. So, together, these domains represent the total disability experience from having a disabled condition and understanding its basic incidence within one's cultural group, all the way to the point of achieving an outcome that is some individualized benefit at the conclusion of rehabilitation services. The five-point continuum conveys that a disability disparity can occur at any point, one point or several points throughout the disability experience as represented by the continuum. Moving down to the next row, you have what I call the hypothesized view of what accounts for differential experiences or what can account for those different experiences. Along this row, this is a reason or a set of reasons that I hypothesize is plausible and to some extent accounts for why there is a differential experience among groups based on cultural orientation at each of these five points. The third row represents the macro-level. This level attempts to offer clarity of the concept of disability disparities at each of the points along the continuum from a big picture vantage point, particularly for researchers who desire to be culturally, sorry, who desire to be conceptually clear about the phenomenon at each point along the continuum. At the fourth row, the level represents the micro-level vantage point. This is a much more up close and personal perspective on factors potentially related to a disability disparity across each of the five domains of the continuum represented in the model. The point of the micro-level viewpoint is to drill down considerably from the previous level's macro attributes to a specific level of abstraction. This more micro-level orientation is designed to offer a set of factors aligned with each of the five domains for practitioners or clinicians to explore to determine if a specific client with a disability is challenged with a disability disparity at any of the five points along the continuum. The model has both a macro aspect and micro aspect, with macro aspect being researchers in terms of clarifying the concept, and the micro aspect being for persons that are providing services to help them explore various things that could be going on at that particular domain on the continuum. Now let's look at the five domains one at a time along the three levels of, hypothesized view of what accounts for differential experiences and disparity, macro-level to clarify the disability disparity concept to researchers, and micro- level to afford a set of factors for practitioners to explore in working with clients. Domain one, this would be those cultural, biological and genetic traditions that influence a cultural group's intergenerational response to oppression, poverty and social stress. At the macro-level in that domain 1, those factors account for a higher incidence of disability among culturally diverse groups. Such factors may derive directly from the cultural, biological and genetic traditions in response to societal pressures that manifest directly into lifestyle patterns, or could be related to other anomalies such as data collection idiosyncrasies when measuring incidence. There are micro- level aspects that practitioners can explore in providing services to specific clients. Those lifestyle considerations, those are lifestyle considerations that could be endemic to the experience of being a member of a group that is ethnically different. Such considerations at the micro-level might be residing in a high risk, high stress environment, and participating in behavior that might be considered to be coping such as self- medication in the case of substance abuse, misuse or abuse, overeating that can be linked to metabolic syndrome, to name a few. Metabolic syndrome by the way is the increased risk for heart attack, diabetes and stroke, that comes with lifestyle issues such as a larger waistline, high blood pressure, higher levels of triglycerides, high blood glucose levels and higher levels of low density lipoprotein. Moving to domain number 2 in the model at the top, the hypothesized reason for a differential experience based on cultural orientation would be, in my estimation, the ethnocentric world view that many systems operate from, or another way of thinking about it, inability of the system in services to embrace pluralistic values and viewpoints. The most systems are designed to not necessarily do well with inverse populations. It is designed with one philosophical orientation or value set in mind. That is what I mean with that particular hypothesized reason. At the macro-level, the main concern is cultural diverse group's perspective on disability at the point that there is actual contemplation about whether to engage with a formal system or not. At this point the person who is a member of a racial ethnic minority group may not actually have access to systems. They are thinking about whether to access the system, so we are talking about the contemplation concept. The potential client contemplates participation in the formal services system. And then moving down to the micro-level aspects, which are things clinicians can explore, some aspects that might be specific to the client's cultural group are things like what does that client's cultural orientation tell him or her about the origin or etiology of the disability? What is the view of typical progression of disability with or without formal system intervention? What is the view of type of intervention that is believed to be effective or efficacious. Those are things the clinician may want to explore on the macro-level too. Domain 3, reason for differential experience is same as for domain 1, the ethnocentric world view that systems seem to operate from, and services seemed to operate from, or inability of system or service to embody or embrace the pluralistic set of values and viewpoints. Macro-level in domain 3, focused on access to formal systems. Previously it was contemplation. We make the assumption the person is going to access the system, so the focus here is on the access piece. At the micro-level there are aspects the clinician can explore providing services to specific clients. There are three of them. One, the role of socioeconomic status in access decisions. We know socioeconomic status can play a role. The idea is to understand what the client with the certain cultural orientation, what role the SES is going to play. We want to get a feel for the group's culturally embedded help seeking tradition. Not all groups think about health seeking in the same way. Some traditions are well anchored culturally. The connection between the rules that govern services system entry and the client's culturally driven help seeking inclination. We know systems all have a set of rules and protocol that allow one to access the system. The question is to what extent is there an alignment or lack of alignment between rules for system entry and the client's culturally imbedded health seeking tradition or inclination. Moving up to the top of the visual, for domain 4, here we are talking about again those hypothesized reasons we might see a disability disparity. In this case what I posit is that there is both practitioner and service system bias at both a conscious and unconscious level, that contraindicates the provision of effective services to culturally diverse groups. People have basically unchecked baggage, if you will, both at the system level and individual provider level, that either consciously or subconsciously contraindicates that effective service delivery for that person who is different culturally. Moving down to the macro-level, the concern is the nature and quality of the service experience. At this point an individual has actually accessed the system and is now arguably receiving services. And so we want to focus squarely on what is the nature of the service he or she is receiving, and what is the quality of the service experience for the client in the formal service delivery system. At this point the potential client has access and is fully engaged in receiving those services. Moving down to the micro-level, again, aspects that clinicians can explore in providing services, it is useful to think about these as prompts that clinicians can have ready to guide their exploration with an individual who is receiving services, to see whether or not a disparity is in fact at work here at this particular domain. The first of the three would be, what is the strength of the treatment alliance between the client and provider? It's a measure of trust. To what extent is there a good relationship and is there good rapport which speaks to how much trust do the two have for each other at that point, particularly the client for the provider. B, the second piece, provider ability to meet the client's cultural expectations. We know in providing culturally efficacious services, the extent to which services can be delivered in a way that meet a person's cultural expectations is the extent to which those services are being viewed as culturally relevant. You want the clinician to address to what extent he or she and provision of services are meeting those expectations that a client may have that are culturally embedded. That is a measure of the extent that provider will be viewed as culturally competent or efficacious. The third piece, the extent there is engagement of services, the concept of how much the person is utilizing the services and the person who is receiving services obtaining an adequate dosage of the services to expect to think about whether or not the outcome or positive impact has been achieved later. Domain 5, at the top of the visual, we have a hypothesized reason for the differential experience. Here it is the same as for domain 4. We are talking about the practitioner and service level system bias, conscious or unconscious, that contraindicate the provision of effective services to culturally diverse groups. It's the same phenomenon that is at work that could account for why we are seeing this difference, this disability disparity for domains 4 and 5. Drilling down to the macro-level, down the page on the right side, domain 5, the primary concern is the bottom line impact of the rehabilitation services. The idea is to be clear that we are talking about to what extent has an individualized benefit from the services been realized by the client; in other words, has the client achieved a positive outcome as a result of interfacing with the service delivery system. Moving down to the micro-level again, realizing we are looking to offer components or prompts or areas that can be a menu, if you will, for clinicians to explore whether or not a particular client is experiencing a disability disparity at this particular domain, domain 5, we have three things. One, we want the clinician to look at the degree that outcomes do align with the client's culture. If we have outcomes, are they in keeping and consistent with what the client's culture would view as appropriate outcome? Secondly, number B, we have the degree that outcomes have been adjusted for different severity levels at the start of services. We know about culturally diverse populations, sometimes they don't access the service system because of the contemplation step at the same rates and with the same speed as other groups. Often when there is access, because of the contemplation, the disability or chronic disease that poses the functional impairment has advanced to a more severe level. We want do make sure we look at outcomes by adjusting them for differential levels of severity at the outset of services. Finally, we want to look at the outcomes as measured both using objective indicators to minimize the influence of bias, and understanding whether an outcome or positive impact has been achieved, as well as we do want to embrace subjective indicators because we do on some level want to accept the fact that the person who's received the services has a right to articulate whether or not he or she has gained anything positive from the experience. This third piece is looking at outcomes objectively, so there is no influence or bias, little influence or bias, and to also look at them with the client's input and bias intact. Okay. That is a quick overview of the model. I know it's fairly quick and a lot there. I want to say that the model does convey that a disability disparity can occur, as I said early on, in one or several points along the five-domain continuum, that in my mind represents the disability experience or at least most of it. It is a fairly broad and fairly conceptual model and hopefully will offer explanatory power going forward. The model, as I said early on as well, is a beginning point in the discussion in talking about disability disparities, by no means is represented as anything definitive. It is a beginning of a discussion, beginning of the conversation. It offers both the attribute of being able to address conceptually what we are talking about each of the five domains at its macro-level aspects, and offers something for clinicians and counselors and practitioners who are working at more micro-level, things they can explore, prompts if you will as they are working with various clientele. At this point, the model has not been validated. I'm fully engaged in activity and thoughts and plans to move forward with doing some validation. And so what I'd like to do is to ask our esteemed panelists, Dr. Rumrill, Dr. Wilson, and attorney Imparato, to give us any broad impressions or observations they have at this point about the model as it's been articulated. Esteemed panelists? >> KEITH WILSON: Yes, this is Keith Wilson. I really like the model. I really like the way the model is outlined, that a disability disparity can occur at any one or several points throughout the disability experience. Talking about the incident participation, the quality of services, and I think the individual benefits and outcomes, I really like that. Also, I think looking generally at the micro-level, this is really interesting because I think this is where the clients and the counselors make these important judgments on one another, and also the systems in which they are both participating. I think lastly, I really have a good impression of this model because if we can get VR counselors specifically engaged in being not PC, not being politically correct, then I think that we can actually have some better outcomes. That is my experience in training master level folks and PhD level folks, that we are still hung up on trying to make people feel comfortable. And we don't even ask those questions many times that would give us more insight in order to help the people that we are serving. Primarily because of enculturation, not acculturation, but enculturation, the kind of stuff that we learn from our group that may be taboo. But I think your model, you are saying that we need to ask these certain questions to facilitate services for the people that we are serving. And I think that should be applauded; outstanding. >> ALLEN LEWIS: Okay. Thank you, Dr. Wilson. Dr. Rumrill? >> PHILIP RUMRILL: This is Phil Rumrill. Appreciate your perspectives, Keith, and I agree completely. I also think that this model really helps me as I think about it to kind of unpack some of the real complexity that goes along with how we figure out how to deal with the different, the various characteristics that our clients and consumers bring to our services. I think for far too long, we have, we try to deal with any characteristic of our clients or consumers really in isolation. So we deal with race and ethnicity and what that implies and portends to culture, and those kinds of things, we deal with disability certainly in our business, sometimes in a vacuum, where we are focusing just on the condition itself, or the impact that it has. But I'm struck through this model of the interaction that occurs between the disability experience and the other experiences and perspectives, including culture, in people's lives. So rather than separating them out, say okay, let's talk about your race and culture, let's figure that out, and then let's talk about your disability and then talk about your car, whether it's running; we are putting all these together in a broader context. It also strikes me just how complex this interaction can really be. So you've got people from different racial and ethnic orientations, who might have a higher incidence of certain types of disabilities, who therefore would need services in a different way than people in other groups. So there is a biological and genetic component as you mentioned as part of the model. Then, culturally speaking, certain groups may be more and less likely to ask for services in the first place. They may be more or less likely based on culture to participate actively or not, or less actively, in the process. They may have a different feeling about people who work for the government, or for, about people who provide help to other people. They may have different conceptions of what a desirable outcome really is. And so we are putting all of this into this process, and so when the client or consumer -- and we are not just talking about people from traditionally underrepresented groups. We are talking really about all people. You have to consider all of these things, and all of these factors, and what things go into that. So it's going to determine people's preferences. It's going to determine the goals. Then of course, there are individual factors even within the groups where you see a lot of variability there, so treating the client as an individual is where our process really has always begun. But broadening out to those group affiliations and understanding the interaction among those characteristics, I think this model helps us to get there rather than looking at these very important but different features of who people are in isolation. >> ALLEN LEWIS: Thank you. Attorney Imparato, any comments from you, sir? >> ANDREW IMPARATO: Sure, thank you. I agree with what my co-panelists have said. I'm still struggling with whether the word "disability disparity" is really going to capture what this kind of model is intending to capture, because as a layperson who doesn't pretend to be an expert in rehabilitation research, but who does a lot of work with kind of mainstream audiences and with policymakers, I think the average policy maker who hears the term, disability disparity is going to immediately think about disparity based on the type of disability. So, if somebody who is blind is more likely or less likely to receive services than somebody in a wheelchair, most people would think that is what you mean when you are talking about a disability disparity. If I understand the model, and the way you have defined disability disparity, that is not what you mean. It can be built into the model, but it sounds like the macro topic of disability disparity refers to disparities in service delivery to people with disabilities based on their race or ethnicity and those people with disabilities. Am I right about that? >> ALLEN LEWIS: Yes, I think you are right. >> ANDREW IMPARATO: So I guess, I don't know if there is another term that we could use, like disability cultural disparities, or something where it would be a little clearer that we are not talking about disparities based on the type of disability, but that the broad category we are discussing here is disparities based on the race or ethnicity of the disabled person. >> ALLEN LEWIS: Okay. Thank you, attorney Imparato. Your point is well-taken. It's an excellent point. Frankly, in my mind I was building on the concept of health disparity and saying, that deals with health conditions, we don't necessarily have an explicit model in the disability literature that deals with disability disparities. But you are right on point. We are talking about cultural disparities or differences in the experiences and outcomes based on these cultural factors such as race and ethnicity. I have to give some consideration to clarifying that. That is an excellent comment. >> ANDREW IMPARATO: Let me just say real quick, I understand why you went from health disparity to disability disparity. In the policy world, health disparity is a branded term, and people understand that it's primarily referring to disparities in the delivery and health outcomes based on race or ethnicity. Disability disparity I would argue is going to draw from a different tradition, which if you look at every reauthorization of the Rehabilitation Act, there is always some groups within the disability community who come into those reauthorizations and say, our community is underserved. And often it's around specific disability categories. So I'm worried that because of the history of certain groups being underserved, not based on race, but based on type of disability, in our world it's going to get confused. >> ALLEN LEWIS: Right. I think you are right about that. There again that is an excellent point, reason for more clarification of that, so that we don't have that other tradition to be invoked and we are talking about the experience and outcomes. Thank you, thank you. I will say a couple things about the model myself. This model has evolved. It is not practice based in terms of the derivation of it. It is something that has come to the service in my thinking as a teaching tool after having taught in this area for ten years. I will say, as most models are, it's very broad and almost has to be by definition an oversimplification of the many complex aspects that it represents. But I do agree with the panelists it's a good beginning point; clearly not perfect. I'm glad that attorney Imparato did give us a point of assignment that the model can certainly entertain, because I was going to say if I hadn't heard anything negative, not that that was negative, but something that was in the interest of continuous quality improvement, clearly there are some things that we can do to the model to make it a better model going forward. It is just a beginning point. I'm very relieved to hear your comment, attorney Imparato, as well as the points of support from both Dr. Rumrill and Dr. Wilson. I did hear from someone else, and I talked about this model in another venue, who asked me a question, how to put the concept of acculturation, how does acculturation fit into the model? Which at that point would have caused me to pause because I know acculturation and I deal with it all the time. As I thought about the model from that perspective, I think acculturation is one of those factors that can moderate the extent to which one is different culturally, if there is such a thing as mainstream culture in the United States. If you factor in acculturation, it is one of those things that begins to moderate the disability disparity to some extent, because acculturation is the extent, as I understand it, to which an ethnic minority or culturally different population is influenced by a dominant population and becomes more similar to that population or that culture. The concept of acculturation is I think a factor in this model. It is just not an explicit factor. It is one of those factors that does in my mind dull the effect of the disability disparity because the more acculturation you have, the more similarity you have across groups as opposed to differences, which is what we are talking about in terms of disability disparity. That is a comment I heard from someone else. I wanted to throw that in. That speaks to a more implicit aspect of the model that is something that needs to be brought to the forefront. Let's move on in interest of time to our final point of discussion. This particular Webcast has not been focused squarely on the idea of addressing strategies for disability disparity in terms of their elimination. But I want to have a moment to at least have a preview of what our panelists are thinking along those lines, because we clearly will have subsequent Webcasts where we will get into that kind of discussion in a much more direct kind of way. Do you have any comments at this point, brief comments that speak to starting the discussion around what strategies are in your mind at this point to address these disparities? Anyone. >> PHILIP RUMRILL: This is Phil Rumrill. One of the things that strikes me right away as we are thinking about the cultural competence or efficacy or humility of the counselor and the practitioner, I think that is very very important, and there are a number of tried and true strategies in both preservice and continuing education models to help counselors become more aware and more sensitive to the perspectives and needs of different groups and individuals within those groups, very very important stuff. I think we also keep coming back in my mind to the ongoing and critical need to improve and increase the level of cultural diversity within the work force of rehabilitation professionals. And that includes diversity in terms of disability status, but in terms of racial and ethnic status and in terms of gender, and in terms of all of these other kinds of characteristics. I think if the profession of rehabilitation counseling continues to strive to look even more like the population of clients and consumers we serve, I think you have got a much greater chance of actualizing this model, and really removing some of these disparities, not in terms of the incidence of disability necessarily, but in terms of the participation, and hopefully outcomes that our clients and consumers can realize. I think there is two parts to it. One is about being sensitive and conscious and aware and understanding where people are coming from and the interaction between disability and culture. But there is no substitute for having a diverse and culturally competent work force, and many of my colleagues in rehabilitation education have spent their entire careers in moving this initiative forward. I think we made a lot of progress, but it strikes me that we still probably have a long way to go. >> ALLEN LEWIS: Thank you, Dr. Rumrill. I would certainly agree. Dr. Wilson or attorney Imparato? Comments? Anybody? Anyone? >> KEITH WILSON: I guess we would feel we would need a more diverse work force, that's, you need people at the table who understand, hopefully, that the programs that we do have in place already may not be hitting the mark with certain groups within the VR system. So that's definitely real clear. I think maybe having access to counselors and also clients, consumers, will be another major step. I see that we are talking about the kind of objective and subjective kind of evaluations, and many times we are kind of looking at the objective kind of evaluations, and not having access to clients and our counselors to kind of institute the subjective, the qualitative part of it. I think that that would be real needed in our field, having access to both clients and also counselors to perform that subjective kind of evaluation, but their experiences, when they are encountering, if you will, people who may or may not be different on a host of variables. As you know, I've come across this once or twice, but when you have that kind of access, that is good. It is almost like having a person to come into your home and you say, come over here, look under the couch, the table. And that is scary, because you don't know sometimes what people may find. But it can I think move the field forward with this kind of factual information we will get from both these ways of knowing. >> ALLEN LEWIS: Okay. Great, that increased access and that subjective viewpoint that we can feed back into how we are providing those services. >> KEITH WILSON: Yes. >> ALLEN LEWIS: All right. Attorney Imparato, anything from you? >> ANDREW IMPARATO: Yes, this is Andy. Please call me Andy. I think both of the other presenters are correct. I guess I would just add a little bit of humility to this discussion, because I feel like there has been a provision in the Vocational Rehabilitation Act for probably more than 15 years, that has called on vocational rehabilitation practitioners to have specific strategies to address underserved populations. I think there has been some awareness in the field of vocational rehabilitation about the lack of diversity in the VR work force, and the lack of cultural competency in some areas of the VR work force. And I guess I don't know, and I'm interested in what the other three presenters feel about this, I don't know that we have made significant progress in the last 20 years. And so I guess I would just examine what has been tried that has been proven to be effective, and what has been tried that it doesn't seem to be working. And I have a lot of theories about what would work. I personally believe that we need to do more targeted outreach and recruitment to get people to go into VR who go to historically black colleges and universities and Hispanic institutions and institutions that have large populations of Native-Americans and other racially and ethnically diverse groups. But I don't know if that's already been tried and failed or if it's not been tried in the right way. We need to do leadership development programs within VR so people who are starting out get quality skills and capacity development so they can (indecipherable) leadership roles in the field of VR. I'd be interested to know out of the state commissioners who run state VR agencies, either general agencies or agencies that serve the blind population, how many of them are people of color and how has that number changed over the last 20 years. >> ALLEN LEWIS: I don't know those numbers off the top of my head, Andy, but I'd take a risk and venture to say probably there hasn't been dramatic change in the numbers over the years, but I could be wrong about that. >> ANDREW IMPARATO: I would agree. >> ALLEN LEWIS: Dr. Rumrill, what about you? Would you agree? >> PHILIP RUMRILL: I would. I'm glad Andy made this point. It's worth considering that some of the same, this model of how clients and consumers access and benefit from services, we might also apply to the decisions that people from different groups make when they think about a career in rehabilitation. So maybe some of those same cultural factors that determine how someone would seek out services might also influence how and whether one would choose to go to graduate school or not, how they make career decisions, or certain groups of people steering themselves away from certain professions for different reasons, you know, those kinds of things. And I think there have been a lot of initiatives to increase the diversity in, certainly in counselor training programs. I think we have been fairly successful in doing that. But I haven't tracked closely where those folks are going when they graduate, and whether certain work settings, are certain groups of people going into certain spheres of our field and not into others? And understanding that it's, it could be some of the same cultural factors that cut across this model that could be determining people's choice to go to certain graduate schools or not, and where we are locating our programs and things like that, as Andy mentioned. These are very very important considerations. This model might be instructive not just in helping diverse groups of people benefit from rehabilitation services, but also in improving the rate of participation in our programs among different groups. Andy also mentioned the fact about leadership in the agencies. On one hand, it would be great to have people doing the direct service kind of work, but we really need diversity at all levels of employment in our business, so that these cultural competencies and efficacy, that those things are infused throughout. We really got to have participation and buy-in at all levels from consumer to direct service provider, regional manager, all the way up to the state commissioners. Andy, I really appreciate your point. You claim an outsider perspective, I'm not sure that is necessarily so. >> ALLEN LEWIS: Good point. Definitely. >> ALLEN LEWIS: Well, sounds like we are moving squarely into the discussion of strategy. That is not the focus of the Webcast today, but we wanted to have a preview of a subsequent Webcast by whetting people's appetites for that discussion. We have been sinking our teeth into that a little and that is good. In the way of moving us to, our time allotment is quickly expiring, moving us to that point of being at the end, let me make two comments. We have made a fair amount of progress in terms of documenting the problem around disability disparity in terms of the research I see, and a few years ago, we did a study at Virginia Commonwealth University where we looked at to what extent has there been more publication activity that deals with issues of culture since the passage of the 1992 Rehab Act amendment, specifically section 21, and we did see -- it was a fairly soft study -- but did see evidence that there is at least more publication activity. What we don't know and what Andy is getting at, to what extent, even though we see more discussion in the literature about this from academics, to what extent has that translated to changed practice? Which is the whole knowledge translation issue, that's the big issue, and one thing the grant is trying to address, we haven't done enough to translate that knowledge into true practice. That is something we need to focus more on. One other comment, as we move into thinking about another Webcast that deals squarely on the issue of strategy to address the elimination of disability disparity, I would offer another model, not my own, but one that has been around for a while from the public health discipline, developed by Bibeau McElroy Steckler and Glanz, that talks about the social ecological model and talks about intervening at various levels, which I heard Dr. Rumrill say and Andy and Dr. Wilson that we need to have strategies that address disability disparity in terms of amelioration both at the individual client level, at the level of the client and his or her contacts, at the level of organization of institutions such as state voc rehab agencies and other service providing agencies, at the level of communities where we have interaction among organizations and agencies that provides services, and hopefully there is corroboration to do more there and at the policy level. As we think about the next Webcast, I'm thinking about a framework, comprehensive framework, i.e., the social ecological model that helps us to begin to think more broadly about the strategies across several levels to make sure we have a comprehensive approach. With that, I want to offer an appreciation to our panelists, Dr. Phil Rumrill, Dr. Keith Wilson and attorney Andy Imparato, as well as to our sponsors and facilitators of the broadcast, the National Institute of Disability, Rehabilitation and Rehab Research, and our project office, Dolores Watkins, VCU empowerment grant team and the SEDL, Southeastern Educational Development Laboratories out of the University of Texas in Austin. To all of you who have joined to watch this Webcast, we appreciate your time and look forward to any follow-up questions that you may send me or any of the other panelists. Please do that. Be on the lookout for more upcoming Webcasts later this year and over the next four years we have this grant that addresses this and similar topics. With that, I'm Allen Lewis, and thank you for joining us today. End of Webcast