AIDS policies and education: what are vocational and residential rehabilitation providers doing?
In recent years, the American public has been encouraged to provide HIV education/prevention programs, personally adopt safer sex practices (i.e., abstinence, condom use, and long-term monogamous relationships), and develop and implement policies regarding HIV infection, prevention, and accommodations in the workplace. At the same time, the public has received mixed messages concerning the value, necessity, or even the urgency of such programs and practices. In a report of the National Commission on Acquired Immune Deficiency Syndrome (1991a), America Living with AIDS, the commission suggests that messages, to be effective, must be much more direct than the early euphemisms such as "exchange of bodily fluids." They recommend the use of "unvarnished language and communication that are both meaningful and acceptable to the particular community or group being addressed" (p. 21). According to the report, "More than a hundred people die in the United States every day of AIDS--one every 15 minutes--and the pace is accelerating" (p.11).
The purpose of this study was to collect initial information on the status of HIV-related educational activities and policies of vocational and residential rehabilitation providers in New York and Indiana, states which represent both the needs and circumstances in middle America and the tremendous problems occurring in large metropolitan areas. The intent was to gather information regarding:
* the extent of education for staff and program participants (clients);
* the extent of policy development and implementation;
* the extent of service provision to persons infected with HIV/AIDS;
* the strengths of the current HIV education programs operated by rehabilitation providers; and
* service provider needs and interest in obtaining further information about HIV education and policies.
The information from this initial baseline assessment has been used to develop an educational curriculum and recommendations for HIV education and policies. The curriculum is being piloted with community rehabilitation providers in New York and Indiana. The results should be available in January 1994.
Although the number of people with mental retardation/developmental disabilities (MR/DD) who have HIV/AIDS at this time is considerably lower than for the population as a whole, implementation of effective HIV education and HIV policies is still needed (Jacobs, Samowitz, Levy, J.M., & Levy, P.H., 1989; Crocker, Cohen, Decker, Rudigier, & Harvey, 1989; Kastner, DeLotto, Scagnelli, & Testa, 1989; Kastner, Hickman, & Bellehumeur, 1989; Decker, 1989; McDaniel & Sells, 1989). As Jacobs, Samowitz, Levy, J.M., & Levy, P.H., and Cabrera (1991) have indicated, this population is at risk due to their vulnerability, sexual activity, presence in the community, and overall lack of sex education and information regarding safer sex practices.
Obtaining national data on the incidence of AIDS among people with mental retardation and developmental disabilities has been difficult due to policies regarding testing and confidentiality and the general overall low rate of testing for HIV. In a 1987 study of mental retardation/developmental disabilities centers in 44 states, 45 people were reported to be HIV positive (HIV+) (Kastner, Nathanson, Marchetti, & Pincus, 1989). A 1990 report by Crocker and Cohen (1991) includes a reference to estimates of the number of adults with mental retardation infected with HIV virus; the revised estimate is now at "over 300." Because of the long incubation period (up to 10 years), the actual number of people with developmental disabilities/mental retardation and AIDS is certain to be higher than the estimated 300.
At the individual state level, more data regarding the number of people with MR/DD who are at risk are available. In a survey of 67 adolescents and adults with MR/DD in Oregon, 39 percent of the adults and adolescents were identified as engaging in behaviors which are high risk for transmission of HIV/AIDS (Hylton, 1989). And in connection with educational needs, only 27 percent of those program participants provided accurate answers to the question: "What can you do to keep from getting AIDS?"
Residential, vocational, and medical rehabilitation providers are encountering HIV/AIDS as they receive referrals to serve persons with AIDS in preschools and daycare and in residential, vocational, medical, and mental health settings. Community rehabilitation providers also are encountering HIV/AIDS as in other workplace settings, through staff and clients who become infected. Because rehabilitation providers are handling more and more HIV/AIDS-related issues, the need to develop HIV education programs and policies is growing.
This study examines the extent of rehabilitation provider activities regarding HIV prevention education and the development and adoption of policies regarding AIDS for two states with different histories and circumstances surrounding the incidence of HIV/AIDS. In September 1991, Indiana reported a total of 1,240 AIDS cases since the Centers for Disease Control began collecting data in June 1981. This figure is approximately the overall median number of cases of AIDS for an individual state. In comparison, the cumulative total of cases of AIDS in New York State was 40,127. The cumulative total for New York City alone was 34,896; this compared to 586 for Indianapolis. Only Los Angeles and San Francisco came close to New York City in cumulative numbers of cases (with Los Angeles reporting 12,714 and San Francisco reporting 10,845) (Centers for Disease Control, 1991).
Members of the New York State and Indiana State Associations of Rehabilitation Facilities (NYSARF's and INARF's) were mailed questionnaires regarding HIV education and policies. Questionnaires were mailed to 219 rehabilitation providers, 140 in New York and 79 in Indiana. Most of these deliver both residential and vocational rehabilitation services and offer a variety of services, including comprehensive vocational evaluations; supported, sheltered, and competitive employment; and independent, semi-independent, and group living arrangements. The Indiana and New York members, while offering similar services, vary in terms of the populations served and size of operations. New York includes proportionately more agencies that provide services to people with disabilities other than mental retardation, such as deafness and blindness/visual impairment. Indiana on the other hand, primarily serves people who have developmental disabilities, mild learning disabilities, and mental retardation. The size of the agencies also varies; more New York members are large, with larger operating budgets. For example, according to records of the National Association of Rehabilitation Facilities, $3.9 million is the largest amount reported for annual salary expenditures by Indiana members; in New York, six agencies report annual salary expenditures ranging from $4 to $26 million.
A two-page survey was developed to measure service provider involvement regarding the following:
* HIV/AIDS Education;
* HIV/AIDS Policy Development; and
* Services to People with AIDS/HIV.
A list of topics addressed under each area is presented in Table 1.
Most questions could be answered with a "yes" or "no" or by checking applicable items. Respondents were also encouraged to provide additional comments and copies of curricula and policy statements already in use.
A written questionnaire was mailed to each member of the Indiana and New York State ARF's in March 1991; a copy of the questionnaire is included in the appendix. The two state associations provided a cover letter or notice in their routine association correspondence encouraging responses. A second questionnaire was sent to nonresponding members in May 1991.
Overall, 118, or 50.3 percent of the ARF members responded: 31, or 39 percent, from Indiana and 86, or 61 percent, from New York. Although every agency did not respond to every question, most respondents answered all of the questions, with approximately one-half of the agencies providing responses to the open-ended questions on education and/or services or supplying information under "additional comments."
Results: Objective 1.
To Determine the Extent of Service Provider Involvement in Providing HIV/AIDS Education.
When asked if their agency was currently providing, or planning to provide, HIV/AIDS education to program participants, 70 percent of the INARF and 72 percent of the NYSARF members responded affirmatively. Fifty-five percent of the New York members and 47 percent of the Indiana members indicated they were currently providing HIV/AIDS education to program participants.
About 70 percent of those either currently providing education and training or planning to during 1991 indicated that the information is being supplied to both staff and program participants. Eleven percent of the agencies (primarily NYSARF members) reported providing or planning to provide HIV education to people in addition to staff and program participants, such as family members and other agencies.
Agencies were asked to identify whether the HIV education materials included information on the nature of the HIV infection, risky behavior, risk reduction, or other content areas. As indicated in the following table, risk reduction was included by the largest portion of agencies and by all of the Indiana respondents.
Responses were generally similar across the two states, with three out of four respondents indicating that all three content areas were included in their program. Forty-four percent of the New York agencies indicated that other areas were also included; none of the Indiana agencies identified additional content areas. The most frequent additions were confidentiality and other policy areas (e.g., nondiscrimination, informed consent) and appear to refer to education for staff rather than program participants. INARF members also were less apt to cover the nature of infection, although this was included in 75 percent of the programs.
A majority (53 percent) of those currently providing or planning to offer HIV/AIDS education to program participants indicated the use of a formal curriculum, with approximately 60 percent of the New York respondents reporting its use compared to only 37 percent of the Indiana agencies.
A total of 63 agencies--10 from Indiana and 53 from New York--provided comments on what they found to be the best features of the curriculum or education program they are using. The responses were generally similar, with New York agencies covering a broader scope of features because of the larger number of respondents. Comments were generally favorable on educational programs, which participants said were written in clear and direct language, were designed for the knowledge level of program participants (many of whom have cognitive impairments), and included current information. Curricula which provided recommendations for flexible use and adaptation for different circumstances, opportunities for group discussions and individual sessions, and the use of local consultants from agencies such as the Red Cross and Planned Parenthood also were viewed positively by the respondents.
The responses are presented in descending order of frequency in Table 4.
A total of 55 agencies, 12 from Indiana and 43 from New York, provided information on concerns and problems. The New York agencies' comments tended to reflect their experience in implementing an HIV prevention curriculum in their individual agencies, while the problems for program participants of the Indiana organizations centered around staff discomfort in relating to HIV/AIDS and HIV/AIDS education and prevention.
The primary areas of concern in both states were about the effectiveness of the education itself, including:
* how well it was targeted to people with mental retardation, especially those whose retardation is considered in the moderate range or below, and targeting for persons with other disabilities (e.g., serious mental illness);
* concerns about retention of information; and
* the transfer of the education to "real life" situations.
A few agencies in each state mentioned some dissatisfaction with the content or media of their current program (e.g., keeping up-to-date). Somewhat surprisingly, only six agencies (four in Indiana, two in New York) identified parental resistance as an issue.
Why Organizations Are Not Providing or Planning to Provide HIV Education
Twenty-five agencies provided information on their reasons for not providing HIV/AIDS education to program participants. The primary reasons in both states was lack of interest or that it was a low priority, followed by resistance from various sources, including sponsoring organizations, staff, and parents, and being in a "conservative community." Nearly 90 percent of respondents in both states--a total of 91 agencies overall--expressed interest in obtaining additional information regarding HIV policies and education programs designed for rehabilitation providers.
Results: Objective 2.
10 Determine Rehabilitation Provider Activities and Needs Regarding HIV/AIDS Policy Development.
Responses on the status of HIV/ AIDS policy development indicate that a considerable majority (79 percent) of the organizations currently have policies in one or more of the areas specified (staff employment, nondiscrimination, education/training, testing and counseling, and confidentiality). New York ARF members, however, were much more likely to have developed policies (83 percent vs. 68 percent among Indiana members), to have policies in place in each of the individual five areas listed, and to have them across all five areas (54 percent vs. 33 percent). Many rehabilitation agencies reported policies in place regarding the use of universal precautions, providing staff training during orientation and annually, and policies regarding record keeping and disclosure of HIV status. Fifteen organizations (10 in New York and 5 in Indiana) had policies in additional areas.
The following table indicates the policy areas covered by the 88 organizations responding to this question.
Interest In Additional Information
Nearly 80 percent of the respondents indicated that they would like additional information on HIV/AIDS policy development. A significantly higher portion of INARF organizations (87 percent) than NYSARF members (76 percent) expressed this interest.
Results: Objective 3.
To Determine the Types of Services Rehabilitation Providers are Giving to People with AIDS or Who are HIV+.
Of 108 agencies answering a question on current service provision to people with AIDS/HIV, 30 percent indicated that they were currently providing services and another 9 percent reported that they did not know whether they were or not. Current service provision to this population was more frequent in New York than in Indiana (32 percent vs. 23 percent).
Services Being Provided
A total of 29 organizations, 7 INARF members (23 percent of the Indiana respondents) and 22 NYSARF members (28 percent of the New York respondents), furnished information on the services they were providing to people who are HIV+ or have AIDS, as follows:
* employment/rehabilitation: 62 percent;
* clinical and support services: 38 percent (New York only);
* services to children with HIV: 14 percent;
* residential services: 7 percent; and
* education and prevention: 7 percent (New York only).
Organizations answering the question reported providing sheltered employment, competitive and supported employment, rehabilitation services, vocational training, residential services, infant development, and "whatever is needed" to persons with HIV/AIDS.
An additional six agencies (21 percent of the 29 total respondents to this question) reported providing the full range of agency services or "whatever is needed." Thirteen agencies (1 in Indiana and 12 in New York) reported that they did not know if they were providing services to people with HIV/AIDS.
Interest in Providing Services
Organizations not providing services to this population were asked if they would be interested in doing so. Sixty-four responded to the question (54 percent of the total respondents). Of these, a total of 47 indicated either "yes" (41 percent) or that they would provide services "as needed" (6 percent). Thirty-three said that they were not interested. Among those not providing services, 62 percent of the Indiana members compared to only 47 percent among New York members indicated they had no interest in providing services. Overall, however, the combined total of those already providing services and those interested in or willing to provide services--while proportionately greater in New York than in Indiana--was nearly 60 percent of the organizations responding to the questions on services.
Thirty-five agencies, primarily in New York State, provided additional comments about services to people with AIDS or who are HIV+. The most frequent comment by organizations in both states was a willingness to serve the HIV population; a strong majority of these respondents, however, indicated that they would provide their regular services rather than establish any specialized services targeted to this population. The second most frequent response (New York only) was that they did not have access to information on program participants who might be HIV+, or that confidentiality policies at their agency precluded them from providing such information.
A strong majority of Indiana and New York members are concerned about HIV/AIDS, are taking steps to educate program participants and staff, have developed policies on HIV/AIDS, and are interested in obtaining further information on both education and policy development.
The primary difference between the two states is that the New York membership is more involved with HIV policy and education issues. This is evidenced by the higher proportion of organizations that are currently providing education to program participants, proportionately more comments on actual experience with curricula, and the higher percentage with policies already in place. However, this is in keeping with the magnitude of the AIDS problem in New York. For example, in New York State, the leading cause of death among Hispanic children 1 to 4 years of age is AIDS; AIDS is the second most frequent cause of death among black children of the same age (GAO, 1991).
Furthermore, in New York City, officials are projecting that approximately 20,000 children will be orphaned due to AIDS in the next few years (National Commission on Acquired Immune Deficiency Syndrome, 1991b). Intravenous drug abuse and prostitution in New York contribute substantially to the number of AIDS cases as well. The impact of AIDS in New York is far-reaching and additional efforts are needed to both prevent the spread of AIDS and assist those who are already infected.
Testing and Counseling
In the current study, 79 percent of all the organizations reported having AIDS policies in place. However, agencies were much more likely to have policies regarding AIDS prevention, staff training, and confidentiality in place than they were to have policies regarding HIV testing and counseling. Only 55 percent of all organizations, 58 percent in New York and 43 percent in Indiana, reported having such policies. The sheer numbers of cases of HIV (particularly in New York), along with the general recognition of the sexual activities and vulnerability of persons with developmental disabilities and mental retardation (Jacobs et al., 1991) support the need for comprehensive policies, including policies regarding testing and counseling.
The relative lack of development of policy regarding testing and counseling, despite its prominence as a policy issue nationally, suggests that this may be an area requiring special attention. The importance of testing and the need for increased testing has also been highlighted in a recent report of the United States General Accounting Office (June 1991). Testing of persons with disabilities and the staff who work with them will increase as the number of people in this population group with AIDS increases and as the general awareness of the American public increases; organizations will need to be ready with policies that address testing, counseling, and confidentiality and, like education, are designed especially for their service populations.
The desirability of developing policies regarding HIV/AIDS for rehabilitation programs is substantiated not only by the AIDS statistics, but by recommendations of professionals working in the AIDS arena. Kastner et al. (1991), for example, have indicated that service providers should be aware that they may be held liable if they:
* fail to treat individuals with HIV/AIDS;
* discriminate in regard to the quality or type of services provided or the individuals who are deemed eligible to receive such services;
* breach confidentiality; or
* fail to provide a safe environment and prevent negligent transmission.
The American Bar Association (Rennert, 1991) has emphasized the need for programs providing services to individuals with HIV/AIDS to be sensitive not only to the broader policy areas, but also to the individual circumstances, and the need to maintain confidentiality not only concerning AIDS status, but also concerning related HIV information such as testing and counseling or the presence of opportunistic infections associated with AIDS.
From the survey of rehabilitation providers in New York and Indiana, two primary HIV education interests emerged:
* Reaching individuals with mental retardation effectively--targeted curricula, materials that are simple and direct, use of videotapes, brochures and other media not requiring high levels of reading ability, ways to help people with cognitive limitations transfer the knowledge from the education program to "real life" experiences, and ways to promote or verify retention of information; and
* The importance of approaches that can be tailored to individuals--targeting to people based on their current HIV risk (e.g., frequent sexual activity with multiple partners); one-to-one education; curricula that can be adapted to different levels of knowledge, learning styles, or level of disability; and approaches that are sensitive to the discomfort and fears that many program participants experience in learning about HIV/AIDS.
There was surprisingly little concern regarding family or community resistance to HIV/AIDS education of program participants, especially considering the attention to this issue nationally (e.g., the Centers for Disease Control requirement that education programs funded by CDC be approved by a community review committee). There was also no mention of coordination with other agencies providing services to program participants receiving education, or to any problems with such agencies.
The American Bar Association (Rennert, Parry, & Horowitz, 1989) cautions that service providers who are aware of sexually active residents but fail to provide appropriate information about HIV transmission may be liable for perpetuating "an environment that is constitutionally unsafe" (p.69). In a discussion of the duty of service providers to protect clients and employees from HIV transmission, the American Bar Association explains that it is far preferable to educate individuals regarding HIV transmission and how to reduce the risks of transmission than to either prevent individuals from engaging in sexual activities (which may violate individual rights) or warn an individual that a partner may be HIV+ (thus risking a breach of confidentiality). More materials on HIV prevention that are presented at a level appropriate to the learning abilities of individuals with cognitive impairments such as mental retardation are needed. These materials need to be presented in a way that provides for mastery of essential concepts; for many people, this will necessitate repeated practice and feedback to facilitate skill generalization.
Although New York members were more likely than Indiana members to be providing services to people with AIDS or who are HIV+, over 60 percent of the combined respondents were not providing rehabilitation services to people with HIV/AIDS.
The most significant finding, however, is that 67 organizations--more than two-thirds of the respondents-- were either currently providing services to this population or interested in doing so, reflecting a clear commitment to service and to nondiscrimination.
It is also clear from the survey that, at the time it was conducted, there was relatively little interest in the development of new specialized services targeted to the HIV population or in providing services to people with AIDS or who are HIV+ who do not meet existing eligibility criteria. On the other hand, the willingness of the majority of the rehabilitation providers to serve this population indicates a need for further information on strategies to provide existing services effectively.
Rehabilitation providers in New York and Indiana, as across the rest of the nation, must grapple with dispensing appropriate services while keeping the risk of transmission low through universal precautions and the adoption of appropriate policies.
The primary implication of the current study is that rehabilitation providers need and want additional information on targeted educational programs that are effective. Furthermore, rehabilitation providers need more information on policies, particularly in the area of counseling and testing.
Another implication is that the majority of organizations provide or are interested in providing their regular services to the HIV population. Information and technical assistance to these programs will continue to be needed as services increase and additional questions regarding policy and education also arise.
Regarding differences between the two states, the slower rates of implementing educational programs and of policy development suggest that technical assistance and information provided to Indiana members may need to be more comprehensive than that provided to New York members. New York also may have more members who are interested in "fine tuning" their programs and policies. At the same time, both states have several members who are not providing education or who have gaps in their HIV policy structure and who want further information and assistance.
This project was funded under Grant #H1283004, Rehabilitation Services Administration, U.S. Department of Education.
Table 1 Content covered by Needs Assessment/Questionnaire (1) HIV/AIDS Education -- Current or planned education or training of program participants -- Major content areas -- Use of formal curriculum -- Best features of curricula being used -- Issues or problems encountered -- Reasons for not providing consumer AIDS/HIV education, if applicable -- Interest in obtaining additional information (2) HIV/AIDS Policy Development -- Status of policy development -- Policy areas covered (if applicable) -- Interest in obtaining additional information (3) Services To People With AIDS/People Who Are HIV+ -- Current provision of services -- Services being provided -- Interest in providing services if not already doing so Table 2 Status of HIV/Aids Education Percentage of Respondents INARF NYSARF Combined Providing now 47% 55% 53% Planning in 1991 23% 17% 19% No 30% 28% 28% Table 3 Content Areas Percentage INARF NYSARF Combined Nature of infection 75% 87% 84% Risky Behaviors 90% 90% 90% Risk reduction 100% 92% 94% All three areas 75% 74% 74% Other content areas 0% 44% 33% Table 4 Comments Regarding Best Features of HIV Education Programs -- Targeting: based on the knowledge level or needs of individuals, adaptable/flexible curriculum, "appropriate level" -- Content: universal precautions, completeness/ comprehensiveness,description of high-risk behavior, "current information" -- Style: direct, factual, simple, clear, practical/relevant, non-threatening -- Presenters: expert consultants, HIV+ individuals, use of local resources -- How presented: 1:1, small groups, discussion, engagement of audience participation, individualized attention -- Media: video, handouts, descriptive brochures, visual aids, resource materials (all New York) -- Structure: use of post-tests, use of repetition, "builds progressively" Table 5 Policy Areas Percentage INARF NYSARF Combined Staff employment 62% 90% 83% Non-discrimination 76% 94% 88% Education/training 71% 88% 66% Testing and counseling 43% 58% 55% Confidentiality 62% 54% 49% All five areas 33% 54% 49%
1. Centers for Disease Control (1991, September). HIV/AIDS Surveillance Report, 1-18.
2. Crocker, A.C., & Cohen, H.J. (1991). Guidelines on developmental services for children and adults with HIV infection. In S. Davis, & M. Lerro, (Eds.), The HIV guide: Resources for board members & administrators (pp. 25-48). Arlington, TX: The Association for Retarded Citizens.
3. Crocker, A.C., Cohen, H.J., Decker, C.L., Rudigier, A.F., & Harvey, D.C. (1989). Affecting the planning and implementation of developmental services for children and adults with HIV infection. (Special Section: Public Policy Affirmations.) Mental Retardation, 27(4), 255-262.
4. Decker, C.L. (1989). Protection of persons with HIV infection: concluding remarks. Mental Retardation, 27(4), 253-254.
5. Jacobs, R., Samowitz, P., Levy, J.M., & Levy, P.H. (1989). Developing an AIDS prevention education program for persons with developmental disabilities. Mental Retardation, 27(4), 233-237.
6. Jacobs, R., Samowitz, P., Levy, J.M., Levy, P.H., & Cabrera, G. (1991). Young Adult Institute's comprehensive AIDS staff training program. In A.C. Crocker, H.J. Cohen, & T.A. Kastner (Eds.), HIV infection and developmental disabilities. Baltimore, MD: Paul H. Brookes.
7. Kastner, T., DeLotto, P., Scagnelli, B., & Testa (1989). Proposed guidelines for agencies serving persons with developmental disabilities and infection with HIV. Mental Retardation, 28(3), 139-145.
8. Kastner, T., Grosz, J., Harvey, D.C., Hopkins, K.M., Murphy, A., Nathanson, R., & Rudigier, A.F. (1991) Human immunodeficiency virus and developmental disabilities: A leader's guide for a workshop. [Grant No. 90DD015 from the Administration on Developmental Disabilities, Office of Human Development Services, U.S. Department of Health & Human Services]. American Association of University Affiliated Programs for Persons with Developmental Disabilities.
9. Kastner, T.A., Hickman, M.L., Bellehumeur, D. (1989, April). The provisions of services to persons with mental retardation and subsequent infection with human immunodeficiency virus (HIV). AJPH, 79(4), 491-494.
10. Kastner, T.A., Nathanson, R., Marchetti, A., & Pincus, S. (1989). HIV infection and developmental services for adults. Mental Retardation. 27(4), 229-232.
11. McDaniel, R.H., & Sells, N.N. (1989). AIDS/HIV policy development guidelines for rehabilitation organizations: A report from the 1989 national leadership AIDS/HIV forum. San Francisco, CA: University of San Francisco, Rehabilitation Administration.
12. Hylton, J. (1990). SAFE: Stopping AIDS through functional education. Portland, OR: CDRC Publications, Oregon Health Sciences University, Child Development & Rehabilitation Center.
13. National Commission on Acquired Immune Deficiency Syndrome (1991a). Americans living with AIDS. Washington, DC: Author.
14. National Commission on Acquired Immune Deficiency Syndrome (1991b). Report: The twin epidemics of substance use and HIV. Washington, DC: Author.
15. Rennert, S. (1991). AIDS/HIV and confidentiality: Model policy and procedures. Washington, DC: American Bar Association, Commission on Mental & Physical Disability Law.
16. Rennert, S., Parry J., & Horowitz, R. (1989). AIDS and persons with developmental disabilities: The legal perspective. Washington, DC: American Bar Association, Commission on Mental & Physical Disability Law.
17. United States General Accounting Office (1991, June). AIDS-prevention programs: High-risk groups still prove hard to reach. (GAO/HRD-91-52). Washington, DC: Gaithersburg, MD: U.S. General Accounting Office.
Ms. Jaskulski is President of Jaskulski and Associates, Highland, MD; and Dr. Mason is Director of Grants and Innovations, National Association of Rehabilitation Facilities, Washington, DC.
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|Author:||Mason, Christine Y.|
|Date:||Sep 22, 1993|
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