Rehabilitation counseling in Appalachian America. (Appalachian Rehabilitation).

Americans who live in Appalachia experience unique and different ways of life than most Americans. Appalachian culture runs from the bottom half of the State of New York through the mountains of West Virginia and Southeast Ohio to the flatlands of Alabama (Appalachian Regional Commission, 1999). This area of the country offers different perspectives and challenges to life. Because of the geographical vastness and uniqueness of the Appalachian culture, many people with disabilities who live in Appalachia are unable to access rehabilitative services and agencies. As verified by Herbert and Cheatham (1998) and Rueda and Martinez (1992), the combination of being a person with a disability and belonging to a minority group, such as living in rural Appalachia, produces a double bias in adjusting to everyday activities. Living in rural Appalachia has its minority features by virtue of geography, unemployment rates, lack of medical services, and limited economic growth.

This paper identifies the geographical area and demographic characteristics of Appalachia, describes the common characteristics that are a part of the Appalachian culture, and provides current statistics of children and adults living in Appalachia who have disabilities. In addition, the authors point out the importance of the impact of the Rural Cultural Diversity Initiative as established by the 1992 Amendments to the Rehabilitation Act of 1973. Finally, the availability of employment opportunities for individuals with disabilities in Appalachia will be discussed, with their implications for rehabilitation services.

Appalachia Geographical Area and Demographics

According to the Appalachian Regional Commission (ARC), Appalachia is defined as a 200,000-square-mile region that follows the spine of the Appalachian Mountains from southern New York to northern Mississippi. It includes all of West Virginia and parts of twelve other states: Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia (see map). About 22 million people live in the 406 counties of the Appalachian Region, and 42% percent of the Region's population is rural, compared to less than 20% of the national population (ARC, 1999). According to the ARC report, the economic fortunes of Appalachia are still based on the extraction of natural resources and manufacturing. However, these areas are now experiencing a boon from tourism because people who live in the urban area of America want to escape from the city and explore remote areas. Unfortunately though, the unemployment rate remains high, and social and health services are scarce and scattered.

During the fiscal year 2000, the ARC identified nine states consisting of counties that have been labeled "distressed" counties. A distressed county, according to the commission, is one that has been targeted as having four areas of immediate concern: income, unemployment, poverty and infant mortality rate. In Appalachian America, income rates are lower, the unemployment rate is higher, poverty is rampant, and the infant mortality rate in some counties is twice the national average.

The following states and the number of distressed counties within those states are identified as: Alabama (3), Georgia (10), Kentucky (40), Mississippi (13), North Carolina (2), Ohio (9), Pennsylvania (2), Tennessee (10), Virginia (5) and West Virginia (26). See Figure 1.

[FIGURE 1 OMITTED]

According to Rehabilitative Engineering Society of North America (RESNA) in a statement from their Rural Initiatives Project Handbook (1996), people with disabilities live in many rural areas across the United States. Unfortunately, the rehabilitative services that people with disabilities need are usually in large metropolitan areas, and such services are simply not available in rural areas. The availability of rehabilitation services is a necessary component to a successful and healthy lifestyle for individuals with disabilities, and this dearth of services needs to be met. For example, the average distance to quality rehabilitative services can be as much as 200 miles away; the nearest critical care hospital may also be as far for some families. This isolation directly affects timely health care services, and the quality of life that individuals with disabilities in rural America experience.

Appalachian Special Characteristics and Features

The characteristics, which are unique to Americans who live in Appalachia, are indeed startling. The following is a brief list, highlighting many of the items of concern by professionals (Child Defense Fund of Ohio, 2001).

* 1 in 5 Appalachian children live in poverty ($14,630 or less a year for a family of three in 2001).

* Over 28% of Appalachian children receive health care through Medicaid.

* 84% of the children enrolled in Medicaid live with working parents.

* Nearly 40,000 Appalachian children lack health insurance (1998).

* 7.6% of Appalachian children are born at low birth weight in 1999, up from 6.3% in 1990.

* Nearly 30% of third graders in Appalachia either have not seen a dentist in the past year, or have never had a dental exam.

* In one Appalachian County in Morgan, Ohio, sixteen children die per 1,000 births, compared to the national average of only 7.8 deaths per 1,000 births.

These characteristics portray a bleak and unfortunate picture for many Appalachian Americans, especially those individuals with disabilities who live in this part of the country.

The Cultural Features of Appalachian America

According to the Appalachian Regional Office of the Save the Children Foundation, communities in Appalachia remain remote and isolated, and homes are usually small, and sometimes just a room in a simple wood frame or trailer. Some homes offer little protection from the harsh winters and springtime floods. In 2002 for example, flooding in the hills of West Virginia destroyed many homes and roadways. People will not however relocate because not only are they deeply committed to the culture, but also many lack the resources to go elsewhere. Some homes even lack indoor plumbing, which is a health hazard, but is commonly accepted as the way of life in this part of the country. Many children in Appalachia live in poor, single-parent families. Their communities lack quality education, and many social and recreational opportunities. Similar to other poor children around the world, these young people suffer from school and health problems. They are also at risk for family and community violence, substance abuse, and early pregnancies. According to the Urban Appalachian Council (1998) located in Cincinnati, there are a number of factors that are unique characteristics of all individuals living in Appalachia.

In Appalachian society, there is a "leveling tendency" in which the statement is often heard, "I'm as good as anyone else but no better." Competitiveness or boasting tends to be frowned upon. Success is not discouraged, but it is how people deal with success that some Appalachians find distasteful. For example, there are an astonishing number of lawyers' offices, all offering no charge for initial consultation on black lung benefits, worker's compensation, injuries, and social security. In one county in Appalachian Tennessee, more than one fifth of a county is disabled from work and a large number of children receive public funds because of their mental, emotional, and physical disabilities.

Duncan (1999) reports that a child's disability check can support a family, and dependence on public assistance is widespread. Volatile employment in mining, combined with high levels of coal-related disability has meant that receiving public assistance is widely accepted and not stigmatized.

The family as a working, impenetrable unit is an important part of Appalachian America. Historically, a tight bond was necessary for survival. For example, each family member has designated chores and responsibilities to keep the family functioning. During the era of America in which agriculture was predominant, this work ethic was instilled and remains in place today for many Americans in Appalachia.

Learning is valued if it can bring a person a better paying job. Notwithstanding though, family comes before educational goals. Blue-collar jobs are not only acceptable, but at times are highly encouraged in lieu of seeking higher education if the education would remove the individual from the family unit and geographical era. Many families encourage their sons and daughters to follow in their footsteps, even if that means going on public assistance.

In Appalachian America, professional labels and titles generally do not mean as much as how the person acts and relates to other individuals. For example, people are often judged by how hard they work in the field, or in the mine and not by what titles or professional degrees they have. Moreover, the culture in Appalachian America is predominately oral, not written, creating a preference for oral communication. Many people often use "hillbilly slang," which is unfairly associated with low intelligence. Moreover, storytelling has always been an important avenue to express and relay information, reinforcing oral communication as the preferred mode of shaping and modifying behavior.

Life flows slowly and incrementally in this part of the country, rather than fast and continuous. Keeping appointments is difficult for folks in Appalachia because of other priorities the individual may have. When Appalachians have met their family commitments, which are considered tantamount, then they will try to make their other appointments. For example, a typical Appalachian farmer may say, "We can't go to a doctor's appointment until the cows are milked and the chores are done," often giving the appearance that their priorities are confused. However, such daily chores are very important to the family unit.

Children in Appalachia are strongly encouraged to follow the footsteps of their parents. Parents want their children to be successful, but at the same time, they feel uncomfortable when they see their children facing futures that are very different from their own. When children in Appalachia have goals and dreams that are different from their parents, there is often not a process by which this change can occur. If change does occur, the change takes place slowly. There is a strong association with the geographical area; if an individual is to leave the area, it might be very frightening.

According to Duncan (1999), a person who works in the county welfare department in a rural Tennessee community was interviewed about the Appalachian community of people with disabilities, and she reports that, "This place is SSI crazy. We get a lot of people in here that are younger than me claiming total disability. They worked in the mines and their backs hurt a little bit, and I tell them, 'maybe you can't get back in the mine, maybe you can get a desk job somewhere or something like that.'" But they say, "Coal mining is all I know (pg. 53)." Duncan reiterates that families do not want to move away from the environment that is so comfortable for them.

Appalachian Americans are usually very guarded about their feelings, especially feelings of a negative nature. For example, Appalachians will take a lot of time to acclimate to strangers, and will go to great lengths to avoid offending others by their words or actions. Appalachians also still value a stem, religious upbringing. Life is family-based and church-based. Social class creates family groups in the region. They are used to doing for themselves, and usually will not ask for help. Many farmers with disabilities will not ask for services, because it takes them away from the farm and their family. Most Appalachian farmers with disabilities, for example, would try to fix it themselves rather than ask for help.

According to Jones (1996), who is a professor at a small college in the Midwest, reports that people in Appalachia choose to remain where they are born because of their profound dedication to family and community. Appalachians are used to doing things the way things have always been done. Roles and responsibilities are handed down from generation to generation. If an individual were to relocate, they would disrupt the family unit and cause change in the family dynamics. Most families live day-to-day without proactive planning for the future. According to one social worker in Southeast Ohio, most clients are women and children whose husbands work in the mines. Spouses get hurt on the job and become disabled, and then they apply for and become welfare recipients. This type of scenario has become the social norm and is widely accepted, according to Eller (1982).

The Impact of Media on the Appalachian Culture

Rehabilitation counselors should be aware that the view of the typical person from Appalachian America has been somewhat stigmatized by popular mediums, such as television, radio, and films. Unfortunately, unless you are from the Appalachian area, the image of Appalachian life presented on television, radio or media scripts is an accurate perception, no matter how formulaic the depiction.

Many depictions of the Appalachian culture in popular media are intended as comedy, and comedy always relies on exaggeration. Even so, it is worthwhile as a counselor to know what is exaggerated and how so; this information is essential if inaccurate stereotypes are ever going to be laid to rest. Such popular television shows that offer an inaccurate portrayal of people of Appalachian America include, The Beverly Hillbillies, Hee Haw, Green Acres, Petticoat Junction, The Waltons, The Gomer Pyle Show, The Andy Griffith Show, The Dukes of Hazzard, and the mountainous movie thriller, Deliverance, just to name a few.

According to Newcomb (1980), Appalachia is perhaps the only region of America to have been systematically stereotyped in fictional context in commercial television. James Bransome (1971), sounded like a man out of his era as he attacked the pervasive set of images that has aimed to define Appalachia in American media:

   Each week millions of Americans gather around
   their sets to watch the combination ["The
   Beverly Hillbillies," "Green Acres," and "Hee
   Haw"] which has to be the most intensive effort
   ever exerted by a nation to belittle, demean and
   other wise destroy a minority people within its
   boundaries. Within those three shows on one
   night of reruns, hillbillies are shown being
   conned into buying the White House, cuddling
   a talking pig, and rising from a corn patch to
   cark the sickest jokes on TV.... America is
   allowed to continue laughing at this minority
   group because on this, America agrees:
   Hillbilly ain't beautiful.

Prototypical stereotypes from the media to portray typical Appalachians include first a representation of the hillbilly stereotype and second is its view of moral superiority. Typical hillbilly characteristics in the media include its view of Appalachian people in the context of physical appearance (e.g. toothless, shabby clothes, dirty, overweight), poor grammatical constructions (e.g., poor grammar syntax, use of "hillbilly slang"), resistance to use of modern conveniences (e.g. outhouses vs. toilets, single coal and/or gas heaters vs. modern electric or gas furnaces, absences of air conditioners, dishwashers or microwaves) which come into play when trying to convince people from Appalachia with disabilities that assistive technology can help them lead an easier life in a variety ways.

The view of moral superiority of rural wisdom is an adage in the media depicting the Appalachian person as shiftless, moonshine "swagging", ignorant and culturally isolated. However, these representations could be misconstrued as virtues of a good heart, simple living, honest values, and a complex insight to human nature.

Health Care Services

Baldwin (1999) states there has been substantial progress in the delivery of health care services in rural areas. However, a chronic shortage of medical professionals and rehabilitative services still exists. Appalachian residents must often travel hours to consult specialists, and many Appalachian rural communities lack even primary health care physicians, specifically specialists in internal medicine, pediatrics, obstetrics/gynecology, dentistry and psychiatry. In fact, according to the Center for Rural Health at the University of Kentucky, Appalachia still labors under a double burden. That is, Appalachia contains the fewest primary care doctors, but the most severe health conditions. These situations are related, because having too few doctors means that dangerous conditions go undiagnosed too long, thus creating an environment for unhealthy children to be born.

Casto (1999) states that America has more doctors than it needs. He argues that is not, however, the case in the nation's rural areas, especially the areas of the Appalachian Region. A recent report from the National Governors Association (1999) indicates that urban areas in the U.S. have 96.2 primary-care physicians for every 100,000 people, compared with 55.6 physicians for every 100,000 residents in the rural areas.

It is not unusual for a big city to have one doctor for every 600 residents, while a neighboring rural county might have only one doctor for every 2,000 residents. Casto (1999) additionally states there are several reasons why physicians do not want to locate in rural areas. Most importantly, rural areas cannot support high-tech specialties in the medical field, limiting the number of physicians. Secondly, some physicians prefer the bigger city life. They feel that a family located in a larger city will attract jobs for their spouses, and increase the quality of educational opportunities for their children. In cities, there are cultural opportunities, such as museums, symphony, ballets, plays, and night entertainment; rural areas lack these attractions.

Moreover, it is not uncommon for doctors, who are practicing in rural areas, to work out of their house. In some cases, this house can be comforting to a person who does not want to drive to the hospital. Duncan (1999) describes one doctor, who is the only doctor in the county and works from his home, and he comes from a powerful coal mining family who was originally from the area. People go to him because he gives medicine away. If you are really sick, he might charge you a minimal amount.

The Appalachian Insurance Dilemma

According to the Child Defense Fund (May, 2001), children in Appalachia are 20% more likely to be uninsured than the rest of the United States. The uninsured rates in Appalachian counties range from a low of 6% to a high of 18.6%. Compared with children who are insured, uninsured children are more likely to be sick as newborns, less likely to be immunized on time, and less likely to receive medical treatment for trauma, injury, ear infections, asthma, tooth decay or other health problems that can cause a disability-related condition.

Medicaid covers twenty-eight percent of Appalachia's youngsters, or over 100,000 children. Public programs, such as Medicaid, are particularly important for Appalachia's working families due to the region's higher poverty rates. This high participation rate reflects the importance that the region places on health care for their children. Because of the shortage of health care in Appalachia, finding a provider who takes Medicaid can be a challenge. As one local health expert put it, "A Medicaid card is like a hunting license: It entitles you to a provider, but you can't always find one." (Appalachian Children's Defense Fund, May 2001).

To deal with the lack of health care services in Southern Appalachia, Tuck (2001) offers this scenario, "The health care system in Appalachia is fragmented. We serve as a 'medical home' for children, not just in my hometown, but also for six surrounding counties. People travel to our practice because they might not be able to find a pediatrician close to home. Families come to me as a primary care physician; either I provide them with or guide them through all the care they need. In this way we help families deal with the shortage of services and providers" (Tuck, 2001).

Cultural Diversity Initiative in Rehabilitation

Section 21 of the 1992 Amendments of the Rehabilitation Act of 1973 describes and identifies the Rehabilitation Cultural Diversity Initiative (RCDI) as a high priority. This initiative aims to ensure the accessibility and equity of rehabilitative services for all minorities in our country, including those in Appalachia America. Middleton, Harley, Rollins, and Solomon (1998), and Smart and Smart (1998), stated that racial, ethnic diversity and disability are linked causing an "inequitable treatment of minorities." This concern is highlighted by the fact that "racial and ethnic minorities tend to have conditions which are disabling at disproportionately high rates." Vocational Rehabilitation (VR) services have been clearly lax when charged with the task of assisting people with disabilities to maximize their employment opportunities. According to Fiest-Price (1995), VR is a major component of assistance for all individuals with disabilities in adjusting to their disability. The RCDI was created to address this obvious need for individuals who live in rural areas in America as well.

Employment Issues

The nation's jobless rate is currently about 5.5% (U.S. Department of Labor, February 2002). In Appalachia, unfortunately, the jobless rate is still very high and, for people with disabilities in rural Appalachia, the jobless rate is almost 68% (Harris Poll Report, 1998). This fact, coupled with plant shutdowns and a poor general economy produces a jobless rate for people with disabilities in Appalachia that is very high. For example, in one county in Appalachia, the prime employer was a window factory that anchored the economy of the county. The unemployment rate of the county was already the highest in Ohio at 24%. Just recently the window plant closed and the unemployment rate in the area increased to 46% (Marietta Times, 2001). This incident is an example of the burdens that people with disabilities face in some Appalachia counties. Moreover, while some jobs are available in the coal and timber-industries, the profits leave the area. Corporate owners of the mines and timberland are from other parts of the country, and reap the reward of Appalachian workers' labor. When there is high unemployment for people without disabilities, there is quite unfortunately, virtually no employment for people with disabilities.

To address this problem, the Family Support Act was passed in 1997 with the purpose of ending welfare, as we know it. While these programs may offer comprehensive support in some states, many poor regions in Appalachia will not gain the benefits of transition-to-work, or work programs. There are simply no jobs; where there are jobs, the competition is very tough (Duncan1999). Finally, most employers would still prefer to hire a qualified person without a disability than a qualified person with a disability (Tuck, 2001).

The Need for Change in Rehabilitation

The Rehabilitation Services Administration is developing and implementing a national policy aimed at preparing individuals from under-represented groups for careers in vocational rehabilitation, independent living, and related rehabilitation programs (Dixon & Wright, 1996). The Rehabilitation Services Administration has engaged in a nationwide, cultural diversity initiative to promote equitable treatment of minority individuals in all major phases of the rehabilitation process, and to provide increased opportunities for minority institutions, organizations, and agencies to help meet their rehabilitation needs. The Rehabilitation Services Administration appears to have established goals to enhance minority involvement via the following systematic changes: (a) recruiting and training minority professionals in rehabilitative service delivery system; (b) increasing the number of institutions of higher education and other minority organizations that successfully compete for grants, contracts, and cooperative agreements in rehabilitation; (c) increasing numbers of individuals with disabilities who are served, employed and have achieved independent living, and (d) committing to promote relevant and useful research that leads to increased and improved services to individuals with disabilities.

Discussion/Solutions to the Problem

Rehabilitation counselors who are working in Appalachian America should know that the culture in this part of the country is unique in many different ways. The culture in Appalachia is different from urban and suburban parts of the country. Pride, heritage, strict family values, and extended families are important facts of this culture. Bauer and Moore-Cooper (2000) suggest that several issues should be addressed to assist individuals with disabilities who reside in rural Appalachia America. They include greater access to social services, more transportation alternatives, improving and maintaining affordable medical healthcare, and increasing employment opportunities.

With regards to accessing social services, most Appalachian families do not like to travel long distances so alternate methods of delivering rehabilitation services should be considered. This includes going to the consumer's home for consultation, delivering equipment to the consumer's house if necessary, and considering home-based services. Formal or informal meetings could be held in a public place like the local McDonald's, church, restaurant, market recommended by the client or consumer's family. Because the family unit is important in Appalachia, a rehabilitation counselor may expect the extended family to attend a counseling and/or rehabilitation session. It is very important to Appalachian Americans to involve the entire family in the decision-making process; Inter-generational support is an integral part of the fabric of life in Appalachia.

The second issue of transportation can be handled in a variety of ways. The Rural Center on Developmental Disabilities at the University of Montana suggests improving transportation by offering grants to buy buses that link school systems and social services. In this way, students can get their rehabilitative services and can return home after the services are completed. Funding mechanisms would have to change so that vehicles can be shared within and across city and county boundaries. For example, in Shelby county Ohio, a local taxi service has been taken over by the county commissioners in an effort to offer tree, or reduced travel for persons with disabilities. People with disabilities pay a dollar for travel anywhere in the county to get to work and/or obtain social services.

Thirdly, a way to counteract the shortage in medical personnel is to integrate a tele-medicine program, allowing families to stay at home, or in their own communities and still receive counseling from rehabilitation professionals and doctors from a remote location. This opportunity can be developed through local public agencies and educational institutions that have videoconferencing equipment. For example, a local agency in rural Southeastern Ohio collaborates with the Medical Center at the Ohio State University for the delivery of services. This collaboration includes genetic counseling and diagnostic services so that people with disabilities can remain in their geographical location.

Three counties in New York (Delaware, Ostego, and Schoharie) have produced a novel remedy to the lack of access to home health care for people with disabilities. With a grant from the Appalachian Regional Commission, homebound patients use televisions and telephones to consult with nurses and doctors, producing telehome visits. These telehome visits allow healthcare professionals to monitor a patient's condition via a video system. These video visits require only a fraction of the time and money needed for at-home monitoring, and allow doctors and nurses to consult with a greater number of patients.

Academic and medical institutions usually require that some internship time be spent in rural areas, especially in Appalachia. Some schools are even offering to refund the expenses of medical school. If a physician decides to reside in an Appalachian area, all or part of their loans for attending school will be waived. Free rehabilitation training programs could be another incentive, or if the student chooses to reside in rural Appalachia Ohio upon completion of their educational or medical program. Perhaps the focus could be on identifying rehabilitation counselors who are successful with rural caseloads to participate in a forum to showcase their best practices.

A mobile, rehabilitation clinic might be developed to bring quality services to the home or geographical area of the person with a disability. A rehabilitation counselor could then coordinate services by bringing together health care professionals and by occasionally chauffeuring them to the remote areas of Appalachia. This would eliminate the ever so apparent problem of client transportation.

Lastly, employment opportunities are scarce for people in this area, not only for people with disabilities but also for people without disabilities. People without disabilities compete with people with disabilities for jobs. If the most qualified individual for a job happens to be a person with a disability, a rehabilitation counselor must advocate for that person's employment. Employment opportunities are highly competitive even for the non-disabled worker. This situation creates an especially poor employment outlook for people with disabilities.

The University of Montana suggests that state and federal programs work with each other, and that counselors should be placed in a state agency with offices in a rural community. Another suggestion would be to link economic development offices and the state agency for vocational rehabilitation. For example, use business development strategies in rural areas to develop jobs, create jobs in tourism, and to enhance value-added agriculture and natural resource industries.

Future Implications

Future implications regarding the provision of services to people with disabilities in Appalachia depend on several issues. People with disabilities are living longer and are demanding the same rights as their non-disabled peers at home, and at work. With this increase, there will be a need for more home-based care rather than hospital and institutional care. More home-based care attendants are required to meet the rural demands of healthcare. People with disabilities will not go away; there is no quick fix or cure. Due to technological advancements in medicine, babies that would have died just 10 years ago are surviving. Most of those infants who are born prematurely will need medical assistance, and their families will need additional support services.

The people of Appalachia depend on traditional and informal mechanisms as the way of life that folks in the communities have utilized for many years. The long-term question, remains how will they transfer those instincts they have for survival into viable assets that are going to allow them to grow and to become independent in the future (Eller, 1981).

Finally, technology will make a difference in the distressed rural Appalachian communities with respect to access to services. For example, there may not be enough money to build community colleges or universities, but a better job of utilizing the expert knowledge through using technological resources and training may be more cost-effective and match the cultural characteristics. The authors propose utilizing the vast tele-conferencing capabilities that to which two-year and four-year colleges have access. By traveling to the local community, a person who lives in rural Appalachia can access medical personnel and services via the electronic web.

In summation, the Harris Poll (1989) stated that employers highlighted the need to have strong collaborative efforts with local governments, rehabilitation agencies, and community colleges so that people with disabilities can earn the right to live, work, and play within their community. To access rehabilitative services, Americans with disabilities in Appalachia must rely upon the ability of rehabilitation counselors to assist them in developing comprehensive capabilities necessary to sustain a quality life and advocate for their lifestyle and culture.

Rehabilitationists in Appalachian America must know the human resource capacity, social resources, and the physical infrastructure necessary for the community to take charge of its own future. It is out of these capabilities that communities will be able to build a future for their citizens with disabilities, and to overcome the burdens of the past. There is no perfect solution; however, rehabilitation counselors must assist in building communities of acceptance. They can capitalize on the strengths and rich heritage of Appalachia. If we know anything from the study of Appalachian American culture and the people who judge it, we know that we can never fully capture the fullness of rich, varied, lived experiences of people with or without disabilities. The images of life in Appalachian America are often restricting and sometimes different. Rehabilitation counselors in this beautiful area of America need to realize that the culture of Appalachian America is alive and well and most traditions are ingrained. We can hardly dismiss them. We can best begin to understand them by offering a creative approach to serving Appalachian people with disabilities in a way that keeps them "home in the rolling hills".

References

Appalachian Children. (May 2001). Ohio's Appalachian children. Children's Defense Fund. Cincinnati, Ohio.

Appalachian Regional Commission. (1999) The Appalachian region. [on-line] Available: www.arc.gov.

Baldwin, F. (1999). A conversation on rural health care. Appalachia, May-August, 1-5.

Bauer, W. & Moore-Cooper, R. (2000). Minorities and rehabilitation counseling. A paper presented at the National Rehabilitation Conference in Cleveland, Ohio 2000

Berry, C. (2000). Southern migrants, northern exiles. University of Illinois Press.

Casto, J. (1996). Rx for the rural heath-care shortage. Appalachia, September-December, 1-8. Coles, R. (1967). The south goes north. Little, Brown and Company.

Dixon, C., & Wright, T. (1996). Service delivery to African Americans with disabilities: How to best train rehabilitation professionals. Rehabilitation Education, 10 (273), 139-150.

Duncan, C. M. (1999). Worlds apart: Why poverty persists in rural America. Yale University Press.

Eller, R. (1982). Miners, millhands, and mountaineers. Knoxville: University of Tennessee Press.

Fiest-Price, S. (1995). Americans with disabilities and equity in vocational rehabilitation services: One state's review. Rehabilitation Counseling Bulletin, 39 (2), 199-129.

Harris Poll Report, (1998). People with disabilities are not being hired. A report on ADA. [Electronic data file]. (1998). Washington, D.C.; National Organization on Disabilities [Producer and Distributor].

Health Department and Vital Statistics. [Electronic data tape]. (1992-94). Washington, D.C.; Appalachian Regional Commission [Producer and Distributor].

Herbert, J., & Cheatham, H. (1988). Africentricity and the black disability experience: A theoretical orientation for rehabilitation counselors. Journal of Applied Rehabilitation Counseling, 19 (4), 50-54.

Isserman, A. (1997). Appalachia then and now: an update of "The Realities of Deprivation" reported to the President in 1964. Journal of Appalachian Studies, (3), 43-69.

Jones, L. (1996). Appalachia characteristics. A review. (1), 1-2. ARC website, www.arc.org.

Killian, L. (1970). White southerners. University of Massachusetts Press.

Malta Windows closes plant. (2001, February 18). The Marietta Times, p 1.

Middleton, R., Harley, D., Rollins, C., & Solomon, T. (1998). Affirmative action, cultural diversity, and disability policy reform: Foundations to the civil rights of persons with disabilities. Journal of Applied Rehabilitation Counseling, 29 (3), 9-18.

Miller, D. (1990). Country comes to town: a survey of Appalachian literature. Now and Then: The Appalachian Magazine, (2) 35-38.

Newcome, H. (1980). Appalachia on television: Region as symbol in American popular culture. The Appalachian Journal, (7) 155-164.

Obermiller, P., Wagner, T. & Tucker, B. eds. (2000). Appalachian odyssey: Historical perspectives on the great migration. Praeger Press.

Philliber, W. & McCoy, C. (1981). The invisible minority. University Press of Kentucky.

Rehabilitation Engineering Society of North America. (1996). Rural initiatives project handbook. RESNA, Washington, D.C.

Rueda, R. & Martinex, I. (1992). Fiesta educativa: One community's approach to parent training in developmental disabilities for latino families. Journal of Association of Persons with Severe Handicaps, (17) 2, 95-103

Schwarzweller K., Brown, J., & Mangalam, J. (1971). Mountain Families in Transition. Pennsylvania University Press.

Smart, J. & Smart, D. (1998). Culturally sensitive informed choice in rehabilitation counseling. Journal of Applied Rehabilitation Counseling, 28(2), 32-37.

Smart, J. & Smart, D.(1998). The racial/ethnic demography of disability. Journal of Rehabilitation, 63 (4), 9-15.

Tuck, R. (2001). Child health: Prime care of Southeastern Ohio, The Prime Care newsletter, (1), 7-9.

U.S. Department of Labor, Bureau of Labor Statistics, (1996). [Electronic data file]. (1996). Washington, D.C.; Bureau of Labor Statistics [Producer and Distributor].

U.S. Department of Labor, Bureau of Labor Statistics, (2002). [Electronic data file]. (Feb. 2002). Washington, D.C.; Bureau of Labor Statistics [Producer and Distributor].

University of Montana: Research and Training Center of Rural Rehabilitation Services, (2002). A center for excellence in disabilities education, research and services. Missoula, MT 59812-7056.

Urban Appalachian Council, (1998). What is it meant to be appalachian? Cincinnati, Ohio, Annual Report, (1), 4-6.

Wagner, T, & Obermiller, P. (1999). Valuing our past, creating our future: The founding of the urban Appalachian council. Berea College Press.

William M. Bauer. Ph.D., CRC, 301 Erwin Hall, Marietta College, Marie, OH45750. Email: [e-mail]

William M. Bauer

Marietta College

Bruce Growick

The Ohio State University