Psychosocial predictors of adjustment to disability in African Americans.

The purpose of this study was to identify psychosocial variables predictive of adjustment to disability in African Americans. Psychosocial variables were social support, self-esteem, health locus of control, and perception of disability severity. Demographic variables were also included as predictor variables. Data were obtained from 170 African Americans who were disabled. The results of a stepwise multiple regression procedure indicated that three of the psychosocial variables, perception of disability severity, social support, and self-esteem, were significant contributors and accounted for 50% of the variance in explaining adjustment to disability in this sample. None of the demographic variables were significant predictors.

One in seven (14%) working age African Americans is Odisabled (Bowe, 1983). African Americans(1) who are disabled have more unfavorable employment, educational, economic, and rehabilitation outcomes than White Americans. For example, a smaller percentage are employed (16% of African Americans compared to 26% of White Americans). Educational level and household income are also lower for disabled African Americans than Whites (Bowe, 1983). Furthermore, access to and utilization of rehabilitation services are not as available for African Americans as White Americans (Atkins & Wright, 1980; Baldwin & Smith, 1984). Yet, many African Americans with disabilities are adjusted to their disabilities and cope well in the home, at work, and in the community. What personal resources do these individuals have that differentiates them from those who are not as well adjusted? The purpose of this study was to examine the psychosocial resources that predict adjustment to disability in African Americans who are disabled.

Four psychosocial variables were investigated. They were (a) social support; (b) self-esteem; (c) health locus of control; and (d) the perception of disability severity. The study investigated and analyzed these psychosocial variables in combination with select demographic variables that were also expected to be contributors to adjustment to disability. These demographic variables were gender, chronological age, educational level, income, and age at onset of disability.

In this study, adjustment to disability is conceptualized as acceptance of disability. Acceptance of disability is based on Dembo, Leviton and Wright's (1956) and Wright's (1960) theory of acceptance of loss. According to this theory, the process of acceptance of loss is a series of value changes. Acceptance of disability is favorable to the extent that a person: a) is able to see values other than those that are in direct conflict with the disability; b) is able to de-emphasize aspects of physical ability and appearance that contradict his/her disabled situation; c) does not spread his/her handicap beyond his/her actual physical impairment to other aspects of the functioning self; and d) does not compare him/herself to others in terms of areas of limitations but emphasizes his/her own assets and abilities.

The facilitative role of social support on mental and physical outcomes of African Americans with disabilities has been demonstrated in a number of studies (Belgrave & Gilbert, 1989; Belgrave & Moorman-Lewis, 1986; Miller, 1986). In a study of chronically ill African American patients, Belgrave and Moorman-Lewis (1986) found that social support was significantly related to the perception of disease severity. In a study of 100 African American disabled persons, Miller (1986) found that family support was significantly related to adjustment to disability. Social support was hypothesized to be a significant predictor of adjustment to disability in the present study.

The results of a number of studies have documented a positive relationship between self-esteem and adjustment to disability (Heinemann, and Shontz, 1982; Linkowski, and Dunn, 1974; Wissel, 1981). In a review of studies on self-concept and acceptance of disability, Linkowski (1988) found that a positive relationship existed between self-concept and adjustment to disability

regardless of age, disability, or other characteristics of the samples. Self-esteem was hypothesized to be a significant factor in adjustment to disability in the present study.

Health locus of control is generalized expectancies concerning health outcomes (Wallston & Wallston, 1983). Persons with an external health locus of control orientation are more likely to feel that health and related outcomes are determined by fate, luck, or powerful others. An external locus of control orientation can lead to the behavioral outcomes of giving up or passively relying on others. Persons with an internal health locus of control orientation are more likely to feel in control of health and associated outcomes. Generally, research has shown an internal locus of control orientation to be associated with more favorable outcomes (Strickland, 1978) than an external locus of control orientation.

In a study of disabled persons, Mazzulla (1981) found a positive relationship between adjustment to disability and an internal locus of control orientation. An internal health locus of control orientation was expected to positively relate to adjustment to disability.

The extent to which a person feels that his/her disability is severe is likely to impact adjustment to disability and related outcomes. Sacks, Peterson and Kimbel (1988) found the perception of illness severity to be a more important predictor of outcome, i.e. mood, than actual illness severity. Kallanranta (1983) found that vocational outcome was strongly correlated with epileptic clients' view of the severity of their disabilities. It was hypothesized that the perception of disability severity would be associated with adjustment to disability.

Method

Subjects

Subjects were 170 African Americans who participated in a study on psychosocial aspects of disability. Subjects were recruited from private and public rehabilitation agencies and facilities in the following cities: a) Atlanta, Georgia; b) Detroit, Michigan; c) New York, New York; and d) Washington, D.C. Subjects were randomly selected from the client rosters maintained at these agencies and facilities.

The age of the subjects ranged from 21 to 82 with a mean age of 44.5. The sample was 47% female and 53% male. Twenty-four percent of the subjects were married, 65% were single (never married), and 11 % were divorced or widowed. Forty-five percent of the sample had less than a high school education and 55% had a high school education or higher. Twenty percent were employed, and 80% were not employed. The majority (55%) of the sample reported incomes less than $5,000 per year with 45% reporting incomes of greater than $5,000 per year.

Subjects were receiving the following types of medical and rehabilitative services at the time of the study: (a) follow-up care by physician (71%), (b) vocational rehabilitation (31%), (c) counseling(2) (20%), (d) physical therapy (20%), (e) occupational therapy (3%) and (f) social services (49%).

Twenty-two disabilities were represented in the study. These disabilities were categorized into four primary categories, (a) speech and hearing impairments (11), (b) orthopedic impairments 18%), (c) mental illness and substance abuse (7%), and other (63%). The other category included a number of disabilities that were represented in small numbers. Some of these disabilities included sickle cell anemia, diabetes, spinal cord injury, cardiovascular disease, respiratory disease, and kidney failure. Procedures

Data were collected in 1985. Each potential subject was contacted by mail or phone and invited to the participating facility to complete a questionnaire. Subjects were provided a nominal fee to cover transportation cost.

Measures

The following psychosocial variables were predictor variables: (a) social support, (b) self-esteem, (c) health locus of control, and (d) perception of disability severity. Demographic variables included as predictor variables were (a) gender, b) chronological age, (c) educational level, (d) income, and (e) age at onset of disability. Adjustment to disability was the dependent variable. A brief description of scales used in the study follows.

An abbreviated version of the(3) social support scale (SSS) developed by Wilcox (1981; 1982) was used to measure social support. The SSS scale measures the frequency of supportive and helpful behaviors performed by others and assesses the subject's perception of the availability of emotional, cognitive, and instrumental support. The scale has acceptable test-retest reliability and criterion-related validity (Wilcox 1981; 1982). Internal consistency of the scale using Cronbach's alpha coefficient for this sample of 170 African American disabled persons was .79.

Rosenberg's self-esteem scale was used to assess global self-esteem. This is a 10 item scale on which respondents are asked to indicate the extent of their agreement or disagreement with items about self. This is a widely used measure of self esteem with established reliability (test-retest) and validity (construct and criterion) (Rosenberg, 1965). Cronbach's alpha internal consistency coefficient for the study sample was .76.

The Multi-dimensional Health Locus of Control (MHLC) scale was used to measure health locus of control (Wallston, Wallston, & Devellis, 1978). This is a commonly used measure of health locus of control. The MHLC scale has demonstrated test-retest reliability and criterion validity (Wallston, Wallston, & Devellis, 1978). Cronbach's alpha coefficient for the sample in this study was moderately low - .45.

Perception of disability severity was obtained by asking subjects to respond to this statement: "In general, how severe, do you think your disability is?" Subjects responded on a four point likert-type scale ranging from 1 - very severe" to 4 - "not at all severe ."

Linkowski's Acceptance of Disability (AD) scale (Linkowski, 1971) was used to measure adjustment to disability. This scale has been used with a number of disabled samples. Studies using the AD scale have shown evidence of high internal consistency reliability as well as concurrent and construct validity (Linkowski, 1988). Cronbach's alpha coefficient for this sample was high -.93.

Results

A stepwise multiple regression procedure(4) was computed to (a) determine the variables that contributed significantly to predicting adjustment to disability; and b) to determine the total amount of variance in adjustment to disability accounted for by variables used in this study.

As shown in Table 1, perception of severity of disability, self-esteem, and social support were statistically significant predictors of adjustment to disability (p < .001). Perception of severity of disability was the strongest predictor accounting for approximately 25% of the variance in explaining adjustment to disability. The perception that the disability was not severe was associated with a favorable adjustment to disability. Thc addition of self-esteem increased the multiple regression coefficient to. 66 and the addition of social support increased the coefficient to .71. Together self-esteem and social support increased the overall variance (R 2) from .25 to .50. Higher levels of self-esteem and social support were correlated with a favorable adjustment to disability.

The three variables accounted for 50% (p < .001) of the variance in predicting adjustment to disability. Health locus of control was not a significant predictor. None of the demographic variables reached a level of significance for inclusion in the regression equation.

Discussion

The results of this study indicate that 50% of the variance in explaining adjustment to disability in African Americans can be accounted for by three variables used in this study- perception of severity of disability, self-esteem, and social support. The findings are consistent with the results of studies which have used samples of White as well as African American persons with disabilities. These studies, reviewed earlier in the paper, showed a positive relationship between these variables and adjustment to disability. Contrary to expectation, health locus of control in this study was not a significant psychosocial predictor of adjustment to disability.

None of the demographic variables contributed to the prediction of adjustment to disability over and beyond that of the three psychosocial predictors. This finding suggests that resources such as income and educational level may not be as important as psychosocial resources in accounting for adjustment to disability with the present sample.

The findings of this study suggest that improving psychosocial well-being of African Americans who are disabled may positively impact their adjustment to disability and related outcomes. Interventions aimed at improving psychosocial resources should be considered by rehabilitation professionals working with African American clients.

The perception of severity of disability was the strongest contributor to adjustment to disability. It is important to note that it was not actual disability severity that was predictive of adjustment to disability but the perception of disability severity. One approach for decreasing the person's perception that his/her disability is severe is cognitive behavioral intervention. Cognitive behavioral interventions are designed to modify the way people process and think about their cognitions and actions (Mahoney, Thoresin, and Danaher, 1972). Cognitive behavioral training can be used to teach the person to realistically appraise the impact of, and the severity of the disability, including his/her assets and limitations. These cognitions may help the person obtain a more realistic perception of the severity of his/her disability.

Self-esteem and social support were also significant predictors of adjustment to disability and made a significant contribution. Programs and activities aimed at increasing self-esteem and social support should improve adjustment to disability and related outcomes. Ways of increasing self-esteem include workshops designed to increase positive feelings regarding self, assertiveness training programs designed to strengthen the person's feelings of control, and activities that promote feelings of accomplishment and competency. One avenue for increasing social support may be to involve the client's larger family and community as sources of support in the rehabilitation process. Encouraging the client to participate in self-help and community groups are other avenues for increasing social support.

The findings of this study are limited to African Americans who are disabled. There are other restrictions on the generality of the study findings. The findings have geographical limitation. Subjects were from New York, Georgia, Michigan, and Washington, D.C. There was no participation from the West Coast. Subjects were clients or participants at rehabilitation agencies or facilities. These subjects may differ from nonparticipants of rehabilitation agencies. Future research using these predictor variables in populations with other persons of color (i.e., Native Americans, Asian Americans, and Hispanic Americans) and more geographically diverse samples are needed to clarify the generality of the study findings.

Footnotes

1 African American is used to refer to Black Americans in this country whose ancestors came from Africa.

2 Counseling was included as a separate category if participants reported that they had received counseling other than counseling

3 received in vocational rehabilitation. The social support scale was abbreviated by this investigator and included ten (instead of 24 items). Items measuring the three types of social support, i.e. instrumental, emotional, and cognitive were included. The internal consistency of the abbreviated

4 scale was acceptable. A stepwise multiple regression analysis was selected to determine the amount of variance added to [R.sup.2] by each independent variable as it enters the regression equation- thereby showing the unique contribution of each variable to adjustment to disability.

References

Atkins, B. J., & Wright, G. N. (1980). The statement- Three views of the vocational rehabilitation of Blacks. Journal of Rehabilitation, 46(2), 42-46.

Baldwin, C. H., & Smith, R. T. (1984). An evaluation of the referral and rehabilitation process among the minority handicapped. International Journal of Rehabilitation Research, 7(3), 299-315.

Belgrave, F. Z., & Gilbert, S. K. (1989). Health care adherence of persons with sickle cell disease: The role of social support. The Annals of the New York Academy of Sciences, 565, 369-370.

Belgrave, F.Z., & Moorman-Lewis, D. (1986). The role of social support in disease severity in chronically ill Black patients. In S. Walker, F. Z. Belgrave, A. M. Banner, & R. W. Nicholls (Eds.) Equal to the Challenge- Perspectives, Problems, and Strategies in the Rehabilitation of the Nonwhite Disabled (pp. 17-22). Washington, D.C.: Bureau of Educational Research, Howard University.

Bowe, F. (1983). Demography and Disability. Arkansas Rehabilitation Research & Training Center. Hot Springs, Ark.

Dembo, T., Leviton, G. L., & Wright, B. A. (1956). Adjustment to misfortune- a problem in social psychological rehabilitation. Artificial Limbs, 3, 4-62.

Heinemann, A. W., & Shontz, F. C. (1982). Acceptance of disability, self-esteem, sex role identity, and reading aptitude in deaf adolescents. Rehabilitation Counseling Bulletin, 25, 197-203.

Kallanranta, T.(1983). Rehabilitation of epileptic patients. Acta-Neurological-Scandinavica, 67(93), 67-70.

Linkowski, D. C. (1971). A scale to measure acceptance of disability. Rehabilitation Counseling Bulletin, 14, 236-244.

Linkowski, D. C. (I 98 8). The acceptance of disability scale: An update, 1969-1983. Unpublished manuscript, George Washington University, Washington, D.C.

Linkowski, D. C., & Dunn, M. A. (1974). Self-concept and acceptance of disability. Rehabilitation Counseling Bulletin, 17, 28-32.

Mahoney, M. J., Thoresin, C. E., & Danaher, B. G. (1972). Covert behavior modification: An experimental analysis. Journal of behavior Therapy and Experimental Psychiatry, 3, 7-14.

Mazzulla, J. R. (1982). The relationship between locus-of-control expectancy and acceptance of acquired traumatic spinal cord injury. Unpublished master's thesis, East Carolina University, Greenville, N.C.

Miller, S. (1986). Patients' perceptions of their adjustment to disability and social support in a community based teaching hospital. In S. Walker, F. Z. Belgrave, A. M. Banner, & R. W. Nicholls (Eds.) Equal to the Challenge-- Perspectives, Problems, and Strategies in the Rehabilitation of the Nonwhite Disabled (pp. 22-38). Washington, D.C.: Bureau of Educational Research, Howard University.

Rosenberg, M. J. (1965). Society and the adolescent self-image. Princeton, N.J.: Princeton University Press.

Sacks, C., Peterson, R. A., & Kimbel, P. (1988, April). The relationship between perception of illness, role disruptions and kidney dialysis treatment. Paper presented at Society of Behavioral Medicine Conference.

Strickland, B. R. (1978). Internal-external expectancies and health related behaviors. Journal of Consulting and Clinical Psychology, 46, 1192-1211.

Wallston, K. A., & Wallston, B. S. (1983). Who is responsible for your health? The construct of health locus of control. In G. Saunders and J. Suls (Eds.) Social psychology of health and illness. Hillsdale, N.J.: Erlbauin.

Wallston, K. A., Wallston, B. S., & Devellis, R. (1978). Development of the multi-dimensional health locus of control (MHLC) scale. Health Education Monographs, 6, 161-171.

Wilcox, B. (1981). Social support, life stress and psychological adjustment: A test of the buffering hypothesis. American Journal of Community Psychology, 9, 371-386.

Wilcox, B. (1982). A measure of social support. Unpublished manuscript, University of Virginia, Charlottesville, Va.

Wissel, E. A. (1981). Analysis of self-concept and acceptance of disability with the traumatic spinal cord injured. A doctoral dissertation, The Catholic University of America, Washington, D.C.

Wright, B.A. (1960). Physical disability: A psychological approach. New York: Harper and Row.

Acknowledgement

Data used in this study were collected by the Center for the Study of Handicapped Children and Youth at Howard University with funding from the National Institute of Disability and Rehabilitation Research. The author acknowledges Dr. Sylvia Walker, Director of CSHCY for her support of this study.

Received:   June 1989
Revised:    November 1989
Accepted:   December 1989