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Employment-seeking behavior of persons with HIV/AIDS: a theory-based approach.

Of the 793,025 cumulative number of persons diagnosed with AIDS in the US since the initial case in June 1981, 96.9% were between the working ages of 20 to 64 years. From 1990 to 1999, the number of persons living with AIDS in the US had increased 400% to 312,804. With the advent of healthenhancing protease inhibitors and highly active anti-retroviral therapy (HAART) in 1995, the longevity for persons diagnosed with AIDS was enhanced. The annual number of AIDS-related deaths in the US decreased approximately 70 percent from 51,670 in 1995 to 15,603 deaths in 2001. As of December 2002, an estimated 384,906 people in the US were living with AIDS (CDC, 2002; CDC, 2003; Karon, Fleming, Steketee, & DeCock, 2001; National Center for Health Statistics, 2002; Vittinghoff, et al., 1999). Medicaid spending on HIV/AIDS totaled $4.1 billion in FY 2000, representing 43% of spending on care and assistance for HIV/AIDS. The mean monthly medical costs for Medicaid beneficiaries were $1,776 or approximately $21,300 per year (Sorian & Kates, 2000).

With the increase of persons living with AIDS and the advent of HAART, there is an increase of persons living with AIDS entering or re-entering the workplace and seeking public vocational employment services (Brooks & Klosinski, 1999; Glenn, Ford, Moore, & Hollar, 2003; Hunt, Jaques, Niles, & Wierzals, 2003;

Kalichman et al., 2000; McReynolds, 2001). Currently, no data exists that identifies the frequency of consumers diagnosed with HIV or AIDS who are utilizing state or federal vocational rehabilitation services, in 2002, the Rehabilitation Services Administration (RSA) acknowledged the frequency of consumers living with HIV and AIDS who were receiving services from state and federal vocational rehabilitation agencies. At that time, the RSA revised the 911 Policy Directive Manual to include HIV and AIDS and initiated data collection on the case closures for these consumers. The initial data analysis is expected to be complete in 2004 (R Nash, personal communication, 20 March 2003). The frequency of PLWHAs on the caseloads of public rehabilitation job placement professionals has been reported in two studies. Timmons and Fesko (1997) reported that among a national sample of 266 public rehabilitation job placement professionals, 35% self-reported a PLWHA on their caseload. In a study sample of 151 public rehabilitation counselors (PRCs) from a population of 186 PRCs in one state in the southern US, 84 (55.6%) self-reported a mean of 3.7 (SD = 4.67) consumers living with AIDS on their active caseloads (Hergenrather, 2001).

Under the Americans with Disabilities Act (ADA), a person living with the HIV or AIDS meeting defined criteria is protected as a person with a disaibility, and further supported by the 1998 Supreme Court case of Bragdon v. Abbott (Americans with Disabilities Act, section 3: Definitions, 1990; McCarthy, 1998). However, even with federal legislation addressing HIV/AIDS, several factors have been suggested to correlate with employment seeking behavior of PLWHAs. Such factors include negative self-perceptions associated with being infected with the HIV, a limited or non-existing work history, perception of a lack of workplace environments friendly to persons living with HIV/AIDS, and the impact of work upon one's adherence to medical treatment regiments (Adam & Sears, 1996; Brashers, Neidig, Reynolds, & Haas, 1998; Brooks & Klosinski, 1999; McReynolds, 2001). The attitude of public rehabilitation job placement professionals toward persons with disabilities is significantly correlated with the consumer's self-concept, personal issues related to the consumer's disability, utilization of the consumer's skills and abilities, and the rehabilitation services outcome (All, Fried, Ritcher, Shaw, & Roberto, 1997; Beck, Carlton, Alien, Rosenkoetter, & Hardy, 1993; Bowman, 1987; Caufield, Carey, & Mason, 1994; Mullins, Roessler, Schriner, Brown, & Bellini, 1997; Watson-Armstrong, O'Rourke, & Schatzlien, 1994). With increasing numbers of PLWHAs seeking employment, disability status for PLWHAs, and the lack of RSA data on the number of PLWHAs receiving public rehabilitation services, no aspect of public vocational rehabilitation services for PLWHAs demands more research than job placement. As the case rates of HIV/AIDS increase, an increase in the number of PLWHAs on public rehabilitation job placement professional's caseloads is likely.

For PLWHAs, employment has been reported as one of the most significant contributions to successfully living throughout their illness and important to their emotional well-being (National Cancer Institute, 1998; McReynolds, 2001; Timmons & Fesko, 1997). Successful rehabilitation service outcomes may be enhanced through understanding the beliefs of PLWHAs toward employment. The needs of consumers of public vocational rehabilitation services demand that public rehabilitation job placement professionals provide services in an expert and proficient manner, resulting in the successful placement of the consumer into a job (Fabian, Luecking, & Tilson, 1995; Gilbride & Stensrud 1993; Millington, Asner, Linkowski, & Der-Stepanian, 1996). A behavioral theory-based approach to understanding the employment seeking behavior of PLWHAs may provide clear and formative data, offer guidelines for identification and selection of variables on which to intervene, and provide topics for in-service training to enhance service provision. The concept of utilizing theory to address specific phenomena in the field of rehabilitation counseling has been presented as one way in which to further develop the empirical foundations of our field (Hershenson, 1993; McAlees, 1993).

Theory-Based Measures

In this study, the authors applied the empirical cognitive theory of planned behavior (TPB) to guide data collection of PLWHAs' beliefs toward working. The TPB posits that a person's behavior is a function of his or her intentions to perform a particular action (Ajzen, 2001; Ajzen, 1988). The TPB suggests that individuals' intentions to perform a specific behavior are guided by particular beliefs leading to valued outcomes if they (a) believe the views toward the behavior held by important others, whom they value, support them to perform the behavior and (b) feel they have access to resources necessary to perform the behavior (Connor & Sparks, 1999).

The TPB suggests that intention is predicted by three cognitive determinants: (a) attitude, (b) subjective norm, and (c) perceived behavioral control. Each determinant consists of a belief, or a set of beliefs, and an evaluation of each belief. Attitude is defined as the individual's perceived consequences of the behavior. Salient beliefs are identified by individuals most likely to perform the behavior. Attitude is influenced by an individual's perceptions of the likelihood of identified outcomes from performing the behavior (behavioral beliefs) and an evaluation of the outcome as being valued as good or bad. Subjective norm is defined as the individual's subjective belief about what those people important to him or her think about performing the behavior addressed. Subjective norm is influenced by the subjective probability that other important individuals think he or she should or should not perform the behavior (normative beliefs) and the measure of his or her motivation to comply with these important individuals. In forming the subjective norm component, individuals take into account the normative expectations of various others in their environment. Perceived behavioral control is defined as the individual's perception of how difficult a behavior is to perform and is consistent with the concept of self-efficacy (Bandura, 1986). Perceived behavioral control consists of beliefs identifying the likelihood of resources for, and impediments to, performing the behavior addressed and evaluating the perceived effect of each resource or impediment as being easy or difficult. Control beliefs are influenced by past experience in performing the behavior and experiences of acquaintances and friends, suggesting exploration and validation of these beliefs (Ajzen & Madden, 1986; Conner & Sparks, 1999; Kohler, Grimley, & Reynolds, 1999).

According to the TPB, behavioral change is ultimately the result of changes in the salient beliefs of the persons performing the behavior. Modifying identified salient beliefs through interventions would create a change in attitude, subjective norm, and perceived behavioral control, and therefore strengthen one's behavioral intentions to perform the behavior addressed (Ajzen, 2001; Ajzen & Fishbein, 1980). The TPB (see Figure 1) has become one of the most widely utilized social cognitive behavioral theories to assess behavior (Conner & Sparks, 1999). The TPB is based upon decades of research (Ajzen, 2001; Ajzen & Fishbein, 1980; Ajzen & Fishbein, 1972; Conner & Armitage, 1998; Conner & Sparks, 1999; Kohler, Grimley, & Reynolds, 1999; Manstead & Parker, 1995; Richard, van der Pligt, & de Vries, 1995). The TPB has been applied in technology training adaptation in the workplace (Morris & Venkatesh, 2000), cooperative learning usage (Lumpe & Haney, 1998), female employment choice (Kolvereid, 1996), student selection of an undergraduate major (Cohen & Hanno, 1993), computer-based health appraisal system usage (Rhodes & Fishbein, 1997), undergraduate student class attendance (Ajzen & Madden, 1986), HIV prevention among adolescents in the UK (Jemmott, Jemmott, & Cruz-Collins, 1992), public rehabilitation job placement professionals intentions to place PLWHAs into jobs (Hergenrather, 2001), ethical decision making (Randall & Gibson, 1991), children's behavioral intentions towards peers with disabilities (Roberts & Lindsell, 1997), career self-efficacy (Giles & Rea, 1999), enrolling in distance education courses (Becket & Gibson, 1998), and enhancing and predicting research dissemination among addictions counselors (Breslin, Li, Tupker, & Sdao-Jarvie, 2001).

Purpose of Study

The objective of this study was to apply an empirical cognitive behavioral theory, specifically the theory of planned behavior (TPB), to identify salient behavioral beliefs, normative beliefs, and control beliefs and explore factors that may affect the intention of PLWHAs to work or return to work. Data were collected from a convenience sample of persons living with HIV/AIDS who received services from the Whitman-Walker Clinic (WWC) in Washington, DC. This analysis is especially important because, the application of theory for the elicitation of a set of cognitive factors facilitating the employment seeking behavior of PLWHAs toward working has not been addressed in the vocational rehabilitation literature and such findings identify specific issues to enhance the provision of public vocational rehabilitation services to PLWHAs.

Method

The study design utilized a quasi-experimental design (Vogt, 1999). A deductive research approach was applied in this study. Such an approach utilizes theory, provides the researcher with a direct and narrow focus and analysis by construct (Burisch, 1984).

Instrument Development

When applying the TPB to the study, it was essential to define the behavior being studied. The behavior is defined in relation to the four elements of action, target, context, and time (Elder, Ayala, & Harris, 1999; Sutton, McVey, & Glanz, 1999). Using the TPB guidelines (Ajzen & Fishbein, 1980; Ajzen & Madden, 1986), the targeted action was defined as becoming employed; the target population was PLWHAs; the context was residing within a large metropolitan area; and the time was the present.

Within the guidelines of the TPB, the Employment Interest Survey (EIS) was developed by the authors to elicit the salient beliefs of PLWHAs. The EIS was an anonymous three-item, free-response, and open-ended paper-pencil questionnaire. Three questions were created to elicit the salient behavioral beliefs, normative beliefs, and control beliefs, respectively: (1) Please list any advantages and or disadvantages of working; (2) When you think about working, there may be a person or groups of people who think you should or should not work. If you think of any, please list them; and (3) Is there anything that would help you start working or stop you from working? If you think of any, please list them. Participants were also asked to report demographic information including self-identified HIV status, gender, race/ethnicity, and highest education level completed. The EIS also included items addressing the participant's (a) employment status, (b) employment history, (c) status as recipients of public assistance, (d) interest in work, (e) current job-seeking activities, (I) identification and utilization of resources to find a job, (g) interest in assistance to find a job, and (h) number of hours a week he or she would like to work.

The content of the EIS was validated by three expert review panels: four faculty members having experience placing consumers with disabilities into jobs from The George Washington University, Washington, DC; two faculty members having expertise in the TPB from the University of North Carolina at Chapel Hill; and the eight member Whitman-Walker management team. Based on the recommendations of the panel reviews, a consensus was found and subsequent minor changes were made to the EIS. The EIS was approved by The George Washington University Institutional Review Board (IRB) and the Whitman-Walker Clinic IRB.

The WWC is a non-profit organization providing health care, social support services, and substance treatment programs to PLWHAs in the Washington, DC metropolitan area. Annually, the WWC serves more than 6,700 persons and provides HIV testing and counseling services for more than 6,000 persons. For a three-month period, the EIS was administered at the Client Services Department reception counter waiting area at the WWC. Routine HIV testing and medical services were provided through Client Services Department. When persons entered the Client Services Department, they would first sign-in at the reception counter and then sit in the waiting area adjacent to the reception counter. At the reception counter, a flyer for the study was posted. Each person completing the standard client sign-in sheet at the reception counter was offered the opportunity to complete the survey while waiting to receive services. If interested, they were provided an informed consent sheet for review. If they agreed, participants initialed the consent form and were given the EIS. Completed surveys were returned to the reception counter. Participants having visual impairments, functional limitations, or not fluent in English were provided assistance service (e.g., readers, writers, translators) to complete the survey. As a protected status under the ADA, participants were not asked their HIV status prior to completing a EIS. Participation in the study was voluntary and independent of services provided by the WWC.

Participants

The EIS was provided to a convenience sample of 479 persons receiving HIV/AIDS service at the WWC in Washington, DC. A participant was selected on two criteria (a) the recipient of services at the Whitman-Walker Clinic and (b) on the EIS, self-identified as living with the HIV or with AIDS.

Analyses

The analyses were conducted within the guidelines of the TPB (Ajzen 1985; Ajzen, 1988; Ajzen & Fishbein, 1980; Ajzen & Madden, 1986). The first step was analogous to a content analysis of the elicited salient beliefs. This consisted of organizing the salient beliefs by cognitive determinants and then grouping similar beliefs together. Beliefs then were grouped by analytic category. For example, family and primary care physician would be analytic categories for normative belief. The exact words of the written belief were used in this procedure. In using the exact words presented by the participants, reader interpretation was reduced (Sims & Wright, 2000). For each cognitive determinant component (e.g., behavioral, normative, control), the frequency of each analytic category was determined. Between three and ten analytic categories, representing the majority of beliefs, became the modal belief statements (Ajzen & Fishbein, 1980).

To address the issue of reliability, the authors measured inter-rater reliability (Sims & Wright, 2000; Vogt, 1999). The first and second authors independently analyzed the elicited salient beliefs of the participant beliefs. They compared broad categories and interpreted individual beliefs according to standard procedures (Rhodes & Hergenrather, 2002). Each elicited salient belief response, for both the behavioral beliefs and normative beliefs, addressed a single topic. However, among the elicited salient behavioral beliefs, the category of autonomy consisted of single statements addressing (a) increasing autonomy and (b) spending time prior to death as one desires. Upon further discussion, the authors agreed to report these as the categories of "increases my autonomy" and "decreases my sense of liberty". Inter-rater reliability was reported at 100%.

Results

Participants

A total of 479 persons completed the EIS, of which 324 (67.6%) sell-identified as living with the HIV or with AIDS. In the sample of 324 participants, 243 (74.7%) self-identified as living with the HIV and 81(25.3%) self-identified as living with AIDS. Participant characteristics included a mean age of 39.6 years (range 18-65); 221(68.2%) self-identified as African American, 224 were male (69.1%), 126 (38.9%) had 12 years or less education; and 204 (63.0%) were unemployed (See Table 1). Of those unemployed, 188 (92.6%) expressed interest in working, of which 169 (89.9%) reported they would like help finding a job. Only 53 (25.9%) of those unemployed identified resources they used to seek employment (e.g., internet, newspaper, family and friends, and employment agencies). Public vocational rehabilitation services was utilized by 6 (2.9%) PLWHAs. Regardless of employment status, 287(88.5%) of the participants stated they would like help to find a job.

Behavioral Beliefs

The first question of the EIS asked the participants to list any advantages and or disadvantages to working. This question represented the behavioral belief component of the TPB. A total of 1,367 salient behavioral beliefs were elicited. A mean of 4.2 salient behavioral beliefs was elicited from each participant. Ten analytic categories emerged, representing 984 (72.0%) of the elicited salient behavioral beliefs (See Table 2). The ten categories represent the modal behavioral beliefs (MBBs) as defined by the TPB. Of the MBBs, 878 (78.3%) identified outcomes perceived as advantageous to working (e.g., increases my income, enables me to become financially responsible, increases my self-esteem) and 116 (l 1.7%) were identified as outcomes perceived as disadvantages.

Normative Beliefs

The second question of the EIS asked the participants to list any persons or groups of people who think they should or should not work. This question represented the normative belief component of the TPB. A total of 378 salient normative beliefs were elicited. A mean of 1.6 salient normative beliefs was elicited from each participant. Three analytic categories were identified, representing 330 (87.3%) of the total elicited salient normative beliefs. Of the normative beliefs, 226 (69.8%) participants identified family; 65 (20.1%) identified friends, and 39 (12.0%) identified the primary care physician. The three categories represent the modal normative beliefs (MNB) as defined by the TPB.

Control Beliefs

The final question of the EIS asked the participants if there was anything that would help them start working or stop them from working. This question represented the control belief component of the TPB. A total of 788 salient control beliefs were elicited. A mean of 2.5 salient control beliefs was elicited from each participant. Of the control beliefs, an impediment to work was reported by 168 (51.9%) participants as a lack of job-seeking skills; by 156 (48.2%) as a lack of job skills: by 130 (40.1%) as the medical instability of a HIV/AIDS prognosis; by 82 (25.6%) as the lack of workplaces that are HIV/AIDS sensitive: by 55 (17.0%) as the potential to lose public assistance; by 49 (15.1%) as the lack of transportation to and from a job; and by 41 (12.7%) as the lack of jobs perceived to provide flexible work schedules to accommodate adherence with prescribed medical treatment. Seven analytic categories emerged, representing 682 (86.5%) of the elicited salient control beliefs. The seven categories represent the modal control beliefs (MCB) as defined by the TPB. All MCBs identified impediments to employment. Of the MCBs, 428 (65.3%) were identified as services addressed by public vocational rehabilitation.

Discussion and Implications

The authors applied the theory of planned behavior (TPB) to elicit salient beliefs of PLWHAs for identifying and exploring lectors that may impact their behavior to work or return to work. Through the administration of the EIS, 20 factors were identified. Although prior research with PLWHAs identified some factors associated with work, no studies were based in behavioral theory (Brooks & Klosinski, 1999; Caufield & Carey, 1994; Fesko, 2001; Glenn, Ford, Moore, & Hollar, 2003; Hunt, Jaques, Niles, & Wierlis, 2003; Massagli, Weissman, Seage, & Epstein, 1994; McReynolds, 2001; and Yelin, Greenblatt, Hollander, & McMaster, 1991).

Several findings from this study deserve highlighting and further exploration. First, the application of the TPB identified ten modal behavioral beliefs, perceived to be the most likely outcomes of working or returning to work for a person living with HIV/AIDS (PLWHA). The majority of elicited salient behavioral beliefs of PLWHAs concentrated on consequences of working that were perceived as advantages rather than disadvantages. Of the 204 participants not working, 188 (92.6%) wanted to work. Regardless of employment status, 287 (88.6%) of the participants reported that they would like help to find a job, suggesting that PLWHAs perceive employment as being a positive outcome that has value. When salient behavioral beliefs are regarded as having a positive value, it is suggested that the person holds a favorable attitude toward that behavior (Ajzen & Fishbein, 1980). Of the ten behavioral beliefs, two were acknowledged by more than 50% of the participants. The majority of participants perceived a financial benefit from working. This suggests that PLWHAs perceive the outcomes of working or returning to work as increasing their income. Of the participants, 112 (34.6%) were unemployed and reported not receiving any type of financial assistance (e.g., SSI, SSDI, TANF, unemployment benefits). Having money was reported as being associated with meeting basic needs (e.g., buying food, having bus fare to medical appointments, having money to buy clothes at the thrift store, moving out of the homeless shelter). One participant wrote," I need a job to help my daughter and me survive." Among PLWHAs, the factor of money can be associated with issues such as independence, security, and stability. It can be important when one is unable to cover basic living expenses (Brooks & Klosinski, 1999). The majority of participants reported that being employed would enable them to become financially responsible citizens. A theme was identified that participants wanted to take care of, and provide for, their families. One participant stated, "To pay my own way. With a job I feel more of a responsibility and like a citizen." More than one-third of the participants perceived that work would increase their self-esteem. Among PLWHAs, the importance of increasing self-esteem has been reported to be associated with the concept of work in American culture and with respected adult status (Sankar & Luborsky, 2003). The employment consequence of increasing self-esteem was supported by the behavioral belief that employment enables PLWHAs to increase their level of self-fulfillment.

Second, the application of the TPB identified three normative referents perceived as being important and influential. The family was reported as the most frequent referent by 226 (69.8%) of PLWHAs, suggesting that participants recognize that their decision to work may be influenced by, and that they are likely to recognize, their family's influence over the influence of friends and primary care physician. One 21 year-old participant wrote on the EIS, "I have an aunt who talks to me about working a lot. She says although I have the HIV I can still attend community college and have a professional career. So that gave me hope that I can work." The family is a major influence on the consumer's adaptation to his or her disability and impacts consumer's motivation to work. The findings suggest that family member's perspective often plays an important role in a person's decision to work. Public rehabilitation job placement professionals working with PLWHAs should work with consumer's family, involvement with family may enable the public rehabilitation job placement professional to (a) elicit the salient beliefs of the family toward the placement of the consumer into a job, (b) understand family dynamics and the impact of these upon consumer motivation, (c) demonstrate his or her competencies to assure that quality services are being provided, and (d) understanding the consumer's role in the family and how placing the consumer into a job will impact that family role. Family is a major influence on the consumer's adaptation to disability and work seeking behavior. When the consumer's family is excluded from the rehabilitation process, components impacting the motivation of the consumer to seek employment may be ignored. Families can provide information regarding effective employment interventions, morale support, and serve as a vital link in informal networking for job opportunities (Alston & McCowan, 1995; Dew, Phillips, & Reiss, 1989; Freedman & Fesko, 1996).

The more a PLWHA perceives a referent (e.g., family member, friend, primary care physician) to view his or her decision to work or return to work as important, the more likely the person living with HIV/AIDS is to perform the behavior of working. In most instances, persons hold favorable attitudes toward the behaviors they perceive their referents to think they should perform, and hold negative attitudes toward behaviors that their referents think they should not perform (Ajzen & Fishbein, 1980). The identified behavioral beliefs of PLWHAs supporting a positive attitude toward work suggests that PLWHAs perceive their families to think they should work or return to work. Although a family member may influence the employment seeking behavior of a PLWHA, that influence may be limited by the family member's knowledge of HIV and AIDS. This influence should be explored and may be dependent upon the family's perceptions of the PLWHA's role in the family (e.g., financial provider, family caretaker). The family, including spouses and significant others, have been identified as an important emotional and informational support for PLWHAs in adjusting to chronic disabling conditions (Burgoyne & Saunders, 2000; Lee & Rotheram-Borus, 2001). In working with PLWHAs, rehabilitation job placement professionals should assist the consumer to identify those important referents and explore interventions, for interacting with the referents, to gain support for the consumer to work. Contingent upon the perceived influence of identified referents, rehabilitation job placement professional may suggest the referent(s) become involved with the consumer's Individual Plan for Employment (IPE).

Third, the application of the TPB, participants identified seven impediments to work which were perceived as likely to occur. This suggests that persons living with HIV/AIDS acknowledge the impact of impediments to, rather than resources for, working or returning to work. Individuals are less likely to engage in behaviors when faced with impediments which have been identified as salient control beliefs (Conner & Sparks, 1999). The identified control beliefs suggest exploration and validation of these impediments. In providing public vocational rehabilitation services to PLWHAs, interventions should be developed to assess the consumer's level of self efficacy for each of the identified impediments influencing employment seeking behavior.

The study findings identified two impediments which were acknowledged by approximately one-half the participants. This suggests that the PLWHAs perceive themselves as not seeking employment due to their lack of job-seeking skills needed to become employed and their lack of the necessary job skills needed to compete in today's workplace. The perceived lack of job-seeking skills was reported as an impediment to working by 168 (51.9%) of participants, suggesting PLWHAs are cognizant of the importance and value of job-seeking skills when seeking employment. Of the 204 participants not working, only 53 (25.9%) identified resources being utilized to find a job. Among the participants, fifteen (7.3%) utilized the Internet, eleven (5.4%) utilized friends and family, nine (4.4%) utilized employment agencies, eight (3.9%) utilized newspaper want ads, and six (2.9%) of those unemployed utilized public vocational rehabilitation services, suggesting that 97.1% of those unemployed did not perceive or identity public vocational rehabilitation services as a resource. Although PLWAs identify the importance of job-seeking skills, they may not be able to identify specific job-seeking skills or resources that provide job-seeking skills. The need to increase job-seeking skills of persons with disabilities has been reported as an impediment for more than three decades (Allaire, Anderson, & Meenan, 1997; Goodwin, 1972; Mannock, Levesque, & Prochaska, 2002; Pumo, Sehl, & Cogan, 1966; Roesler & Bolton, 1985). In working with PLWHAs, rehabilitation job placement professionals should further explore this issue.

Of the participants, approximately one-half identified their lack of job training as an impediment to working. A person's perception of his or her level of occupations skills and how the skill level serves as a barrier to employment may determine the diligence with which one seeks employment. Atkinson, Lee, Dayton-Shotts, and French (2001) suggest that self-perceived competence in basic skills (e.g., reading, writing, math) and in unskilled labor (e.g., manual labor, assembly line work) increased the probability of employment. Among persons with disabilities (e.g., HIV/AIDS), it would be important to explore the correlation between diagnosis status and perceived skills as barriers to employment. Among PLWHAs recently released from prison, one's perceived lack of job seeking skills and perceived need to be trained in new job skills were identified as impediments to seeking employment (Sowell, et al., 2001).

Approximately two-fifths of the participants identified the medical instability of their prognosis as an impediment to working. Health-enhancing protease inhibitors and highly active antiretroviral therapy have enhanced the longevity for persons diagnosed with AIDS. However, the likelihood of access to medical treatments and adherence must be explored among PLWHAs. Although PLWHAs may be eligible for public assistance through the Social Security Administration, 112 (54.9%) the 204 participants who were unemployed did not receive any type of medical case management assistance and relied on family, friends, and shelters for support. Of those receiving public assistance, 42 (37.5%) received SSI, 43 (38.4%) received SSDI, and nine (8.0%) received TANF. If a PLWHA is not aware of available medical resources, the lack of information is an impediment throughout their prognosis. Many challenges exist for PEWHA in the medical management of stabilizing HIV disease, which include anemia, co-infection, hepatitis C, hematologic abnormality, fatigue, dementia, and extent of support system (Burgoyne & Saunders, 2000; Orsulie-Jera, Shepard, & Britton, 2003; Vittinghoff, et al., 1999: Volberding & Sullivan, 2002).

The study findings can be integrated into public vocational rehabilitation services. Utilizing the Vocational Rehabilitation Process (Institute on Rehabilitation Issues, 2003, p.46), a PLWHA Job Placement Enhancement Model (see Figure 2) could be introduced during the Planning Stage and impact the IPE Stage and the hnplementation Stage. The employment beliefs of PLWHAs would be identified in three steps: (1) Exploring the consumer's perceived likelihood and value of the ten consequences of working and develop interventions to enhance the identified beliefs: (2) Identifying consumer's important referents, their impact upon the consumer's decision to work, and explore the involvement of the identified references in the process: and (3) Exploring the consumer's perceived resources for, and impediments to, work and assess his or her level of control (self-efficacy) over each of the seven control beliefs to develop interventions to enhance consumer self-efficacy. During each of the steps, the public rehabilitation job placement professionals develop and evaluate consumer-centered interventions to change beliefs and enhance consumer empowerment. Behavior change is the result of changes in the beliefs of persons performing the behavior (Ajzen, 2001).

Conclusions based on this study are subject to several limitations. First, a convenience sample was used and may not be representative of PLWHAs. The study sample must be interpreted in regard to its limitation. The sample is limited in its representation of women and Hispanic/Latino Americans; which were actively recruited as participants. Therefore, beliefs specific to the employment-seeking behavior of women and Hispanic/Latino Americans may not be represented in these findings. Second, participant's self-reports on the Employment Interest Survey may have been biased by a reluctance to answer questions he or she may have perceived as having relevance in evaluating one's eligibility to receive services, social desirability concerns, and "faking good," (Streiner & Norman, 1995). Third, self-reports of beliefs regarding working may not translate into actual job seeking behavior. Despite the limitations, the study provides the first empirical evidence that the TPB provides a structure to identify job-seeking behavior of PLWHAs and suggests specific issues to address for enhancing employment.

With increasing case rates of HIV/AIDS in the US and the disability status of HIV/AIDS, it is likely that public rehabilitation job placement professionals will have increasing numbers of PLWHAs on their caseloads. The study findings suggest that the majority of PLWHAs want to work. They perceive the consequences of employment as earning an income, becoming financially responsible, and increasing one's self esteem. Participants acknowledged that their ability to seek employment was influenced by their family, and impediments to, rather than resources for, obtaining employment. Additional studies should examine the relationship between the findings of this study and the intentions of public rehabilitation job placement professionals toward placing consumers living with HIV/AIDS into jobs. In utilizing theory-driven methods to explore job placement beliefs of consumers with disabilities, we would build upon the experience and research of predecessors in our field of public rehabilitation services. The concept of utilizing behavioral theories to address specific phenomena in a discipline has been presented as one way in which to further develop the empirical foundations of the field, substantiate the phenomenon being measured, and enhance the clarity of research studies (DeVellis, 1991; Hershenson, 1993; Hershenson et al., 1981; McAlees, 1993).
Table 1
Demographics of Participants (N=324)

 Sample US cases of
Characteristic N (%) PLWHAs (%) (a)

HIV status
 HIV+ 243 (74.7) 281,931 (42.3)
 AIDS 81 (25.3) 384,906 (57.7)

Gender
 Female 95 (29.3) 164,649 (24.7)
 Male 224 (69.1) 502,188 (75.3)
 Transgendered 5 (1.6) na

Ethnicity/Race
 African American 221 (68.2) 302,627 (45.4)
 Caucasian American 76 (23.5) 249,549 (37.4)
 Hispanic/Latino American 22 (6.8) 105,176 (15.8)
 Other 5 (1.5) 9,485 (3.4)

Age
 <15 na 5,854 (0.8)
 15-24 22 (7.1) 15,948 (2.4)
 25-34 68 (21.8) 107,640 (16.1)
 35-44 119 (38.1) 284,062 (42.6)
 45-54 82 (26.3) 187,399 (28.1)
 55-64 19 (6.1) 51,792 (7.8)
 [greater than or equal to] 65 1 (.6) 14,142 (2.2)

Educational level
 8th grade 11 (3.4) na
 Some high school 32 (9.9) na
 High School diploma/GED 83 (25.6) na
 Some college 110 (33.9) na
 Bachelor's degree 59 (18.2) na
 Master's degree 25 (7.7) na
 Doctorate 4 (1.3) na

(a) Source: Centers for Disease Control and Prevention (2003).

Table 2
Modal Behavioral Beliefs (N=984)

 N (%) Percentage of
 participants

 1. Increases my income 177 (18.0) 54.6
 2. Enables me to be financially 164 (16.7) 50.8
 responsible
 3. Increases my self-esteem 112 (11.4) 34.6
 4. Increases my social interaction 109 (11.1) 33.5
 with others
 5. Increases my autonomy 90 (9.1) 27.8
 6. Increases my level of self-fulfillment 86 (8.7) 26.9
 7. Increases structure in my life 71 (7.2) 21.9
 8. Exacerbates HIV-related complications 64 (6.5) 19.8
 9. Increases my quality of life 59 (6.0) 18.2
10. Assimilates me into a work environment 52 (5.3) 16.1
 that is not HIV/AIDS sensitive.


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Kenneth C. Hergenrather

The George Washington University

Scott D. Rhodes

Wake Forest University

Glenn Clark

Whitman-Walker Clinic

Kenneth C. Hergenrather, Ph.D., MSEd, MRC, CRC, Department of Counseling/Human and Organizational Studies, Graduate School of Education and Human Development, The George Washington University, 2134 G ST. NW.; Rm. 318, Washington, DC 20037. E-mail: hergenkc@gwu.edu
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