Rural issues in rehabilitation service delivery: a Goodwill Industries of America study.

Rural America offers a unique challenge in vocational rehabilitation service delivery. Because urban models often do not address issues that are specific to rural populations, new models specifically suited to a rural environment need to be developed and refined. Furthermore, the rural universe is not homogeneous: issues pertinent to some rural areas do not exist in others. A critical step in laying the foundation for the development of rural specific service delivery models is identifying those elements which are common to rural areas and those which substantially differentiate rural populations from their urban counterparts. This study, presented here in abbreviated form, attempted to isolate issues which might impact the outcome of rehabilitation programs when implemented in rural areas. Variations between rural versus nonrural communities in service delivery and outcome, in community characteristics, funding availability, and prevalence of types of disabilities were identified. Some rural service delivery centers were found which developed their own unique way of overcoming rural barriers; these are presented by way of sharing some innovative methods which might prove useful to others.

This study is offered as a contribution to what is hoped to be an increased endeavor to address the needs of rural populations.

Background

Rehabilitation professionals working in rural areas customize service delivery models to suit their environment and often find themselves struggling with barriers that are not clearly addressed, if at all, in models typically developed based on urban factors and circumstances. Urban centers, with their larger client base, have been the focus of attention in addressing rehabilitation issues. Consequently, over the course of time, most successful program models have evolved based on the profiles of urban communities.

Projects With Industry programs, for example, have proven very effective in urban and suburban areas. The programs are based on two principal components: providing skills training and placement in competitive positions at completion; and making use of a Business Advisory Committee (BAC) for guidance, feedback and, possibly, as a source of potential job opportunities. While programs such as these have been adopted by rural rehabilitation centers with some measure of success, they do not take into account rural-specific issues which can present significant barriers to improved programs outcomes. Some of these issues may include the selection process for BAC participants, the types of rehabilitation programs implemented, and community specific considerations such as access to transportation, social attitudes, and family support.

Rural areas, with their different lifestyle structure and values, present a unique challenge. The disadvantaged and disabled rural population is underserved and has become a target for national rehabilitation policy.

The Goodwill Server

Goodwill Industries was thought to provide a valuable platform for the study of rural versus nonrural issues in rehabilitation because of its structure (nationally, it is comprised of 173 local organizations) and its experience in rehabilitation service delivery (Goodwill Industries has been providing rehabilitation services to rural communities as well as nonrural communities since 1902).

Of the 173 Goodwills surveyed nationwide, 78 organizations responded. Unfortunately, there was no followup opportunity to assist in determining the cause for nonresponse.

While statistically we cannot make valid conclusions regarding the experience of Goodwill organizations overall due to our relatively low rate of response, we felt that the information collected offered a valuable resource and a basis for further investigation.

Respondents showed a high interest in the subject. Many of the respondents who claimed that they served a uniquely nonrural community expressed a desire to extend their services to a rural community nearby. Overall, the response breakdown is as follows:

* Roughly 50 percent of Goodwills responded;

* 13 Goodwills, 17 percent of the respondents, characterized themselves as 100 percent rural;

* 22 Goodwills, 28 percent of the respondents, described themselves as completely nonrural;

* The remaining 43 organizations represent a mix of rural/nonrural components.

"Rural" Communities

Previous studies dealing with rural communities have invariably sought to provide an adequate definition of "rural." In truth, there seems to be no single set of criteria for defining ruralness. Social, cultural, and economic factors which define community life influence our understanding of the rural-urban conceptualization. While in the past urban and rural may have been viewed as a dichotomy, increasingly they are understood as opposing ends to a continuum. Improved access to modern technology and communications by traditionally "rural" areas have blurred some of the cultural variations between rural and urban places. Nonetheless, the community's self-perception and the human ability to adapt to these changes typically lag behind. Community attitudes and dispositions, geographic remoteness and population densities, and industrial and economic characteristics are all factors which must be taken into account in defining an area as rural. These are the same factors which we must ultimately take into account in developing a successful rehabilitation model for rural communities.

The Goodwill study asked participants to define their community as either urban, rural, or a mix. Those who served a mixed community were asked to specify the extent to which they considered their territory rural. This approach was utilized based on the concept that, ultimately, "rural" has a look and fee, an experiential attribute, and that it is a continuum rather than a discrete entity. We chose to accept their perceptions and profiles of the "rural" communities they serve. This offered perception was measured against the economic structures and industry distributions of the counties served and subsequently validated against U.S. Census data profiles utilizing accepted criteria of land use, population densities, and industrial prevalence.

Employment in Rural Areas

Respondents to the Goodwill survey who served a partially or fully rural community claimed that the employer composition in their area was predominantly a mix of small and medium size businesses with staff sizes of up to 100 (36 percent of respondents). The second choice response to employer composition was "mostly small businesses with less than 30 employees" (32 percent of respondents.)

Predominant employment mode was identified as manufacturing by 48 percent of respondents claiming to serve a 25 percent rural or less rural community, while respondents who claimed a high percentage of ruralness in their community identified retail employment (40 percent) as predominant and manufacturing as secondary (33 percent). Those Goodwills who claimed a low "degree of ruralness" (e.g., they serve a rural and a nonrural community and claim that their rural community constitutes the smaller share) serve counties which are primarily nonrural and are more closely to d to metropolitan areas (as measured by percent of population in Metropolitan Statistical Areas, or MSA's). Since rural manufacturing counties have greater population densities and proximity to MSA's, the primarily nonrural Goodwills would be expected to show a greater predominance of manufacturing industries. However, Goodwills identified as primarily rural are less related to metropolitan areas and have lower population densities. They might be expected to be more closely aligned with farming and, because of the relative lack of manufacturing jobs in these areas, retail employment would be expected to hold a larger share of nonfarm labor.

Diversity in Industry

Predominant forms of industry are an important factor in the formulation of policy relating to rural issues. It is, therefore, important to note that a uniform industrial anatomy does not exist in rural communities. We can construct a framework, however, that will allow us to classify rural communities into major industrial categories. One such framework is offered by the United States Department of Agriculture Economic Research Service (ERS). ERS makes a major distinction between metropolitan and nonmetropolitan counties (those inside and outside MSA's). The nonmetropolitan counties are categorized on the basis of economic activity. The four most prominent categories are:

* Farming, which applies counties with at least 20 percent of total labor and proprietor income from farming between 1975 and 1979 (702 counties);

* Manufacturing, which applies to counties with at least 30 percent of total labor and proprietor income manufacturing in 1979 (678 counties);

* Destination Retirement, which applies to counties for which net immigration of people 60 and older for 1970 to 1980 represented at least 15 percent of the 1980 population over 60 years of age (515 counties); and

* Government, which applies to counties where government activities accounted for at least 25 percent of earnings in 1979 (315 counties).

This system provides an indication of the diversity and complexity that exists in the social and economic structure of rural America. In developing a model for rehabilitation service delivery to rural communities this diversity requires careful consideration.

Rural Versus Urban Services

Identifying differences in rehabilitation service delivery between rural and urbanized areas provides information useful to tailoring programs to maximize their efficacy. The Goodwill study attempted to gather some information to isolate characteristics which might indicate variations between rural and urban sites. This was particularly of interest since a great number of Goodwills claimed to serve both types of communities.

Types of rehabilitation programs used and frequency of use were essentially the same for Goodwills serving rural and urban communities. This is as expected, since there is no policy in place to promote a different approach to rehabilitation based on community ruralness.

The percentage of Goodwills which offer job skills training, job seeking skills, and job coaching is substantially lower in rural areas. This may be partly reflective of lesser availability of "job seeking skills training" funding. The job skills training categories which are computer-related - data entry and computer programming - are markedly lower in rural areas as compared to their nonrural counterparts.

The study found that the distribution of Goodwill clients served across programs and skills training areas as fairly consistently between rural and nonral groups. The data does indicate a tendency towards higher utilization of office and computer skills training in nonrural areas and a greater utilization of retail and cashier training in rural areas. This conforms to the relative importance of retail businesses to rural areas confirmed by other analyses in the study.

Availability of job skills training programs is low among rural Goodwills, with only 33 percent of sites serving rural communities offering this type of program. Where they are offered, a lower percentage of clients receive assembly training (6.9 percent vs. 19.9 percent) and a significantly higher percentage receive janitorial training (46.8 percent vs. 26.2 percent compared to Goodwills serving nonrural communities. The number of clients served who utilized retail/cashier jobs skills training tends to increase with the level of ruralness (12.6 percent for nonrural and 21.1 percent for rural). (See Table 3-B).

The placement of clients in outside jobs in rural areas falls short of the benchmark identified by the nonrural component of the survey. Of the 17,320 reported clients served in nonrural areas 30 percent (or 5,130) were placed in competitive outside jobs, while only 16 percent (or 762 clients) of the 4,895 clients identified as rural were placed in outside jobs.

Job coaching programs in rural areas are better utilized where there are higher levels of service employment (as defined by the U.S. Census). Overall, job coaching program utilization tends to be lower in more rural areas (as indicated by percent rural and percent of population inside Metropolitan Statistical Areas).

Sheltered employment and work adjustment training were found to be dominant approaches used in rural areas, capturing 38 percent and 30 percent of the responses, respectively. This pattern is mirrored for those Goodwills which consider themselves exclusively rural, although the split is more pronounced - 61 percent use "on the job" training as opposed to 23 percent who rely most heavily on work adjustment training.

Projects With Industry (PWI) programs are utilized to a larger extend by respondents serving an exclusively rural community than by those which serve a mixed community. There are higher placement levels for sites offering a PWI program to their rural communities than for sites not offering PWI. However, success rates fall short of the levels established in nonrural areas running PWI programs.

Funding Sources and Services

Centers serving rural communities were asked to identify funding sources having a presence in their areas. State vocational rehabilitation was by far the most frequently cited source (96 percent), followed by the Job Training Partnership Act and mental health/mental retardation centers (both cited by 86 percent of respondents). Social services/welfare was cited by 78 percent of respondents, and Veterans Administration was cited by 55 percent of respondents.

Centers serving rural communities were also asked to state which services were most frequently funded. Vocational evaluation was cited 83 percent of the time, followed by work adjustment services which was cited by 80 percent of respondents.

Respondents were asked what they perceived as the major obstacles in operating a rehabilitation services facility in the communities they served. While urban service delivery centers stated that availability of funding was the top concern (45 percent), rural Goodwills showed that transportation issue (59 percent) as the main concern, followed by funding availability and the ability to secure full-time employment.

Study participants were asked to identify the types of populations in their communities which, in their opinion, represented the group with highest needs.

Prevalence of Disability

Overall, needs relating to mental illness, learning disabilities, and economic disadvantage dominate perceived needs in rural communities, despite the high levels of work-related physical disabilities generally associated with rural areas.

Goodwill Industries of America publishes a yearly Statistical Report wherein the clients served by each member Goodwill are presented by type of disability.

As part of the study on rural issues, the Goodwills describing themselves as serving rural communities exclusively or in addition to urban communities were asked to indicate the type of client population they served.

People with orthopedic disabilities, mental retardation, learning disabilities, and those with overall severe disabilities were the predominant client populations served by those Goodwills identifying themselves as serving an exclusively or predominantly rural community. Conversely, the nonrural Goodwills showed a prevalence of disadvantaged client population as compared to this population in those Goodwills serving rural communities.

The Goodwill study showed that people with mental retardation and learning disabilities were perceived as having a greater need, while those with orthopedic impairments rated lower on the "needs perception" scale. The higher proportion of this population in the actual clients served may be reflective of policy by funding sources which refer clients to the Goodwill sites.

Conclusion

In summary, the Goodwill study indicate the following framework for understanding the dynamics of rural rehabilitation:

* There is great diversity in economic activity across rural America. While extractive industries such as farming remain an important factor and manufacturing plays a critical role in many rural areas, retail and service jobs dominate the nonfarm employment in rural communities.

* Small and medium sized businesses are the primary mode in rural areas.

* Jobs seeking skills training and sheltered employment programs are more difficult to fund relative to other programs in rural locations.

* People with mental and learning disabilities and economic dislocation are perceived as the categories of greatest need in rural areas, superseding physical impairment modes of disability. In terms of clients actually served, rural rehabilitation programs are more focused on people with physical and mental disabilities than programs in urban areas.

* Jobs skills training, job coaching, and job seeking skills training programs are less available in rural districts, perhaps in part as a result of difficulty in funding.

* Sheltered employment and work adjustment training are the dominant approaches used for job preparation in rural locations.

* Twenty-five percent of the Goodwills responding that claimed a rural component utilize a PWI or similar program in their rural area. Rural PWI's are more prevalent in exclusively rural locales. PWI programs in rural areas demonstrate effectiveness in generating placements, but do not match the success rates found in urban environments.

* Transportation obstacles and funding are identified as the major problems perceived in the operation of rehabilitation programs in rural communities.

A look at some existing models can provide a guideline to other innovative ways of providing rehabilitation services in rural communities. In the Goodwill experience, four sites - Dayton, Ohio; Muskogee, Oklahoma; Knoxville, Tennessee; and Reading, Pennsylvania - have taken initiatives that made their service delivery systems more effective in the rural communities they serve.

The Dayton Experience

Goodwill Industries of Dayton, Ohio, has developed a program for rural areas. Mobile vocational marketers have been equipped with car phones and laptop computers. Clients unable to travel are visited in their homes. A modified job seeking skills curriculum is used. Because of the self-contained nature of smaller rural-based economic centers, separate, locally composed Business Advisory Councils have been proposed for each of the rural counties served. The Rural County Project based in Dayton has increased fourfold in terms of placements and has consistently exceeded its placement goals since its inception in 1987.

The Muskogee Experience

Goodwill Industries of Muskogee, Oklahoma, (population approximately 70,000) developed a health care training program for people with disabilities. The Muskogee Goodwill used the BAC to provide program leadership and community coordination among the various health care agencies. The BAC serves as the coordinating body by joining social service and health care providers together for the purpose of sharing resources such as program staff, space, and materials. Some of the lessons learned by the Muskogee Goodwill BAC include:

* Be knowledgeable of the local political structure; understand who holds the "power," (mayor, city council, church leaders). Who you have on your side may determine failure or success.

* People living in rural areas want to "do for themselves" and resent outside interference. To be accepted as part of the community is essential. Members of the BAC should be carefully selected with this point in mind.

* Transportation is a big issue. Agencies working together can alleviate some of the costs and help coordinate the linkage communication network which will benefit everyone.

* There is no room for duplication among service providers, due to limited available funds.

The Knoxville Experience

"Urban Rehab in a Rural Setting" is not only the title of the Goodwill Industries-Knoxville, Tennessee, rural program but also describes the approach used to provide rehabilitation services in rural counties.

Three satellite centers have been developed in mountainous rural communities surrounding Knoxville. Each of these satellites operates a retail outlet production/processing area and a small self-contained rehab unit. In addition to a sales manager at each center, each rehabilitation unit is supervised by a rehabilitation services manager.

The "rural" segment of the program is performed by a job coach whose primary responsibility is to develop a community-based training sites and provide transportation to rural clients to and from the job site.

A rural vocational services marketer has been employed who will coordinate the activities of all three satellites and serve as the primary community liaison on developing separate BAC's for each of the three satellite centers.

First year program expectations include providing rehabilitation services to 75 people with disabilities and the competitive employment of 45 people back into these three rural communities.

The Reading Experience

Goodwill Industries of Reading, Pennsylvania, provides services in rural areas in two counties, utilizing a one-on-one job coaching mode. This type of training and placement service allows for every individual service in job placement, job seeking skills, on-the-job training, and other support services that may be necessary. Each county operates with a separate BAC that is made up of members who represent the variety of businesses and industries in that area.

While the high rate of unemployment in Schuylkill County represents a challenge in developing job openings, most often transportation is the biggest challenge in providing employment. To address this problem a Transportation Committee was formed representing providers, consumers, funding agencies, the transportation system, and the intermediate unit to develop alternatives to getting people to work. Mass transit training is provided and a program which matches people needing with people who have transportation is being developed. The group also advocates through local planning efforts to ensure that the needs of people with disabilities are addressed.

The cooperative efforts created through the transportation committee are also very useful to network in small communities.

Educational Cooperatives

Another popular and difficult alternative used to address rural problems in vocational program delivery involves the formation of educational cooperatives. Cooperatives join schools and rehabilitation agencies for sharing such resources as programs, staff, and technology. Collaborations hold many potential benefits for those involved, including:

* Access to a greater variety of programs (vocational assessment, in-service training, and staff development and guidance and counseling by qualified personnel);

* Greater economic efficiency in cost savings via share staff and programs and the elimination of unnecessary duplication of effort;

* Advantage of joining together for services while maintaining the benefits of a small agency; and

* Reduction of resistance to change in rural areas.

(Helg, 1984; Jansen, 1988; Kerwood & Starsen, 1988; Kirmer et al., 1984; Parrish & Lynch, 1990)

The models noted above offer viable approaches dealing with the problems typical to rural rehabilitation programs. Drawing on the experience of existing and past models which address rural communities and benefitting from this study and ongoing research in rehabilitation service delivery for rural areas, the proposed model was designed by Goodwill Industries of America to better address existing needs in rural areas.

A Rural Service Delivery Model

The proposed service delivery model is a PWI model geared especially to the needs of the rural client. It utilizes techniques proven successful through the Goodwill experience.

Healy and Porter (1981) state that the career development process is crucial for working in rural communities. Sarkees (1979) asserts this process should be undertaken as a coordinated effort involving the training program, home, and the community.

The proposed approach emphasizes the participation of home, community, and business as essential partners in the effort of preparing and placing people with disabilities from rural communities into viable career paths.

The service model has six principal interrelated characteristics:

* Case Management

* Rural Marketing

* Career Development Program

* Business Advisory Council

* Community Participation

* Family Involvement

Case Management

Where services can be rendered at a facility, the rehabilitation counselor assumes the role of case manager. In this role, the counselor receives the client for service, helps him/her develop the Individual Written Rehabilitation Program (IWRP) and provides or refers the client for appropriate services to fulfill the plan - guiding and counselling the client through the process to integrate the various services.

Where services are delivered at a centralized facility, as is the case at many Goodwill sites that offer a wide range of services, the rural model must address the distance and transportation obstacle. The rural client often lives too far. The role of the case managers is to assess the needs of the client and either transport those services to the client's area or supplement the services through available community resources.

Rural Marketing

The Rural Marketer role developed in the Dayton model seems to have worked successfully, and is included in the proposed service delivery model. The marketer's job is twofold:

* To market the rehabilitation center's services to people with disabilities in the rural areas.

* To develop the employability potential of clients served by enlisting the cooperation of family, potential employers and the community.

The Rural Marketer should be provided with sufficient support to allow extreme mobility and to increase his/her effectiveness in the wider and more remote areas found in rural settings. A mobile office with phone and laptop computer will enable the marketer to effectively maintain contact while traveling to community centers, churches, schools, offices of other service providers, the service delivery facility, and clients' homes.

Services such as vocational evaluation, skills training, and support services can be negotiated with community organizations (e.g., job training centers, schools) and job development can occur through employer visits, job listings and the like as is done in other PWI placement projects. The Rural Marketer will organize job clubs, broker a range of career services, and market the incorporation of career development services into the special education school curriculum.

Career Development

The career development process is a self-directed assessment, planning, and educational program. The counselor acts as a facilitator to guide the participant through the acquisition of information, understanding, knowledge, and skills that a client needs to establish, develop and plan for short- and long-range vocational goals.

The process will utilize assessment information gathered from the client prior to program entry through the evaluation of existing records, vocational evaluation data, feedback from occupational training, and vocational counseling sessions. The process involves 12 components: self-awareness, career and personal assessment, career awareness, career exploration, career decision making, career planning, skills training, job seeking skills, job readiness training, placement services, career preparation, and followup services.

Business Advisory Council

The proposed service model is a system that must include the direct involvement of the local business community, employers, and potential employers with the rehabilitation service center. The Business Advisory Council is the vehicle for such active participation. The council can provide job opportunities, assist in the development of job and readiness skills training, and advise the project concerning labor market needs and training requirements. Utilization of countywide Business Advisory Councils provides a genuine industry/rehabilitation partnership in which both the rehabilitation service providers and employer assume shared responsibility for integrating qualified people with disabilities into the mainstream of the world of work. While local BAC's are characteristic of PWI models, the operation of such councils on a countywide basis is unusual.

Community Participation

A critical component of this proposed rural service delivery model is community participation. While community involvement is always desirable in any model, in the rural community it becomes critical to the success of the model. Close-knit communities, skepticism of outside intrusion and the cultural gaps that exists between urban and rural populations make it imperative to solicit community participation as an integral part of the rural model.

A community advisory council will assist the project in identifying possible clients and obtaining services to assist in developing the employability of clients (e.g., transportation, child care assistance, etc.).

This group is made up primarily of social service providers (e.g., state vocational rehabilitation, JTPA, mental health, welfare services, school administration, etc.). Recognized community leaders must be identified and invited to participate in the community advisory council. Members of the council should be included in all stages of model implementation in order for the service delivery program to gain acceptance in the rural environment.

Role of Family

An important potential asset to the client as he/she goes through the career development process is the family. While this is true in all rehabilitation programming, it is especially true in the case of rural clients. Research has shown that parents are the single most important influence in the career-planning and decision-making process of their children (Drier, 1987). Families in rural areas tend to be closer knit and involved in each others plans and undertakings. In sparsely populated areas, the family knows a greater proportion of the community than in urban settings. With the relative lack of specialized services, families help one another in emergencies and resolving community issues and are active participants in a wide variety of community activities.

Thus, the family has a richness of informal contacts that can help the disabled family member access needed services or locate job openings. The client will be encouraged to enlist this resource in fulfilling his/her vocational goals.

Alternative Models

The Rural Service Delivery Model outlined above was developed based on the findings of the Goodwill survey and the success achieved by the initiatives of the various Goodwill centers presented in this paper. To date, the proposed model has not been formally tested.

Other useful systems can be developed. Certainly, the current deficiency found in rural rehabilitation indicates that they must be developed. Richard B. Offner, Director of the Research and Training Center on Rural Rehabilitation Services at the University of Montana offers the following:

"While developments in modern society have reduced the pronounced rural-urban differences that classical sociologists wrote about, rural-urban locality based differences do exist. Thus, social science fact supports the case that we need different rural service models. Importantly, the divergent factors and/or barriers that affect the ability of rural clients to live independently require rehabilitation personnel and services capable of providing innovative and often untraditional service approaches" (Offner, 1990).

This study, the Goodwill experience we shared, and the ensuing proposed rural service delivery model outlined above are at attempt to address the unique needs of rural Americans who are disabled and disadvantaged. Now the work must begin.

Bibliography

[1.] Bluestone, H., & Myers, P.R. (1987). Rural manufacturing on upswing again. Rural Development Perspectives, 4(1). U.S. Dept. of Agriculture Economic Research Service. [2.] Carlin, T.A. (1987). Rural areas weaning themselves from farming. Rural Development Perspectives, 4(1). U.S. Dept. of Agriculture Economic Research Service. [3.] Foss, G., & Kelly, S. (1990). Rehabilitation education in rural environments Rehabilitation Education, 4, 143-147. [4.] Goodwill Industries of America, Annual Statistician Report - 1989. [5.] Heady, S., & Porter, R. (1990, Fall) Meeting the needs of the rural disadvantaged: A comprehensive approach. The Journal for Vocational Special Needs Education, 5-6. [6.] Kraus, L.E. & Stoddard, S. (1989). Chartbook on Disability in the United States. Washington, DC: U.S. National Institute on Disability and Rehabilitation Research. [7.] Majchrowicz, T.A. (1989). Patterns of Change in the Rural Economy, 1969-86. U.S. Dept. of Agriculture, Economic Research Service, Rural Development Research Report No. 73. [8.] Offner, R.B. (1990, November). Rural rehabilitation: A challenge for the 1990s. Journal of Rehabilitation Administration. 97-98. [9.] Rojewski, J.W. (1990). Issues in vocational education for special populations 1-7. [10.] Sarkees, M.D. (1990, August). Meeting the needs of at-risk learners in rural areas: Challenge for the 1990s. TASSP Bulletin, 1-4. [11.] U.S. Bureau of the Census (1988). City and County Data Book - 1988. Washington, DC: U.S. Government Printing Office.

Ms. Larsen has operated an information and management consulting business, AQUAS, Inc., since 1979. She has recently worked as staff researcher for Goodwill Industries of American, Inc. She is currently providing consulting and research services to the Agency for International Development. Mr. Foley is the Projects With Industry Coordinator at Goodwill Industries corporate headquarters in Bethesda, Maryland.