Considering work for people living with HIV/AIDS: evaluation of a group employment counseling program. (Work for People HIV/AIDS).
With the advent of protease inhibitors and combination therapies, many people living with HIV/AIDS (PWAs) have experienced a relative stabilization of their health. They have prospects of an extended future that can now include the realistic likelihood of employment (McReynolds, 1998). The process of this disease is unpredictable, with setbacks, complicated side effects, difficult and intrusive medical regimens, and a variety of psychological effects (e.g., anxiety, depression). The volatile disease profile, characterized often with sudden reversals of health, can force the individual to modify or abandon a positive educational or employment experience. The nature of both the disease and its medication regimen mean that the path of considering work is more unpredictable for the person living with HIV/AIDS than it is for a person with a more predictable disease profile (Anders, 1996; Canadian AIDS Society, 1998; Carton, 1996; Kohlenberg, 1997).
These features of the disease process add an extra complication for service organizations that wish to actively assist PWAs to consider entry (or re-entry) into some form of employment. Agencies that have traditionally served PWAs (AIDS service organizations = ASOs) have mostly focused on medical and psychosocial issues--prevention, regimen adherence, symptom treatment, support. Many ASOs now find that the option of work is increasingly feasible for their clientele and need guidance on how to respond to the challenge of vocational counseling for this population. Research on the employment counseling process and support for PWAs is limited although service agencies and grass roots organizations are increasingly called upon to respond to these new needs.
There are various models for vocational counseling for people with HIV/AIDS. Some generalize from other disabilities and are based on the classification of AIDS as a formally defined disability under federal law. For reasons that are discussed elsewhere (Kohlenberg & Goldblum, 2001), it is recommended that a multifactor model be used that takes into account the unique characteristics of the HIV/AIDS disease. The recommended model includes the four essential factors involved in considering work for PWAs (medical, financial/legal, psychosocial, and vocational). The model also takes into account the capricious course of the disease and the difficulties of its treatment.
Although it is a matter of debate whether HIV/AIDS shares major similarities with other disabilities in its impact on employment issues (Martin, Brooks, Ortiz, & Veniegas, forthcoming; De Lima, et al., 1997), it is clear that more information is required about appropriate models of vocational assessment and counseling and on the efficacy of employment counseling for this population. A limited but growing number of studies have begun to document empirically the relationship between HIV/AIDS and employment (Blalock, 2001; Brooks, Ortiz, Veniegas, & Martin, 1999). However, there is little direct evidence of the effect of employment counseling for this population (Cherrick & Skampski, 2000). The research reported here is intended as contribution to understanding these effects for HIV/AIDS clients using a group counseling program as a research vehicle.
There are also important practical considerations to this examination. Many vocational counselors in public and non-profit organizations have limited experience in helping PWAs. Moreover, they may not have programmatic freedom or ability to adapt their methodologies to the needs of this special population. Vocational counselors in public sectors often serve clients with a wide variety of disabilities and may not know enough about HIV/AIDS specifically to address clients dealing with its unique features. Service providers who do have special knowledge of HIV/AIDS often do not have, or have not yet had the time to develop, a systematic set of services that support the process of entry/re-entry to work for PWAs. Either of these potential sources of employment services for PWAs may depend on classic "back to work" models that implicitly assume that returning to work is a linear process of behavior change and skill acquisition. But experience with PWAs (and perhaps with other disabled populations) shows that the actual process is unpredictable because of endemic factors, such as the disease process, or of exogenous factors, such as developments in the system of benefits and medical insurance. These considerations call for a fresh look at the vocational counseling process, one that takes into account not only the special needs of clients with HIV/AIDS but also the professional needs and tools available to both vocational counselors and AIDS support programs.
This paper provides an evaluation of a pilot program that was created to meet the needs of PWAs considering a possible return to work after varying periods of absence from the work force. The program was designed to meet cognitive vocational information needs of clients, while providing a group support environment. In addition to these considerations, there was the third, less obvious goal--testing a group format that might be effective in organizations with limited counseling resources and staff. This evaluation provides an analysis of the cognitive and affective outcomes associated with the process and presents some tentative conclusions about the potential of group-based vocational counseling. Last, although this issue is not addressed in detail here, it is hoped that this model can be helpful in assessing rehabilitation needs for other disabilities that share some of the inconsistent nature of the HIV/AIDS disease.
The discussion that follows will (a) provide a basic outline of a group employment counseling program designed to assist PWAs, (b) present information from a focus group comprised of a subset of "graduates" of the program, and (c) analyze pretest and posttest data on client outcomes. The concluding section extends the discussion to broader issues of vocational rehabilitation for people living with HIV/AIDS.
Group Employment Counseling: The "Making a Plan" (MAP) Groups
The Making a Plan (MAP) group counseling program began as a project of the Positive Resource Center, a San Francisco agency offering employment services and benefits counseling exclusively for people living with HIV/AIDS. The group counseling program was developed to accommodate increasing client need while operating within an environment of limited staff availability. The program recognized that one of the barriers inhibiting workplace participation of PWAs was the lack of sufficient vocational rehabilitation resources to serve the growing number of clients wishing to expand their personal options and develop new work goals (Emerson & Causey, 1998).
The group counseling program offers HIV-positive people career counseling support while they identify and plan training and employment goals in a series of eight weekly group sessions. The goal of program participation is the development of a personal plan for training and employment, though there are also goals related to psychosocial support and amelioration of cognitive and affective barriers to considering work. The group model inevitably serves as a support group for some non-vocational needs, but all participants are expected to focus on employment.
From September 1999 through December 2000, five separate groups (with a total of 67 participants) participated in an eight-week program. The groups were advertised to clients of the Center and acceptance was based on client commitment to attending the eight weekly two-hour sessions. Service coordinators of the agency specifically recommended participation to clients they identified as in need of and ready for the structured support of the program. Clients who were not interested in working, who were not physically or psychologically able to work, or who would not be consistently available during the eight scheduled weeks were encouraged to enroll in later groups. No one who self-identified as interested and willing to participate was excluded from participation.
Of the 67 participants, all but one were male. Ages ranged from 26 to 56, with a mean of 42 years. Mean education was about 15 years with a range of 11 to 19 years. Of the 60 who were unemployed, the time since last work ranged from one month to 16 years, averaging 4.8 years. Seven individuals were in some form of employment. Fifty-eight (87%) were white, six (9%) Hispanic, and three were African-American (4%).
Because no comprehensive survey of potential clients exists, it is unclear how well this sample represents the potential San Francisco Bay area PWA clientele for vocational counseling. The demographic distribution of HIV/AIDS has changed in recent years and currently contains higher proportions of non-whites, youth, and females than the sample of this study (see, for example, studies by Brooks et al., 1999, and by Blalock, 2001. It is unknown whether, or how soon, this changing demographic pattern will be reflected in the make-up of clienteles actually preparing to consider work entry or re-entry (refer to this issue in the concluding discussion). Prior work experience and available skills varied considerably among the participants, of course, and these factors affect the scheduling of possible re-entry to the labor force. However, the program is designed to help clients assess these very factors and make an appropriate plan for their situation and needs. The evaluation of participant outcomes focuses on their progress in reduction of perceived barriers and acquisition of appropriate vocational information.
Goals of the Group Employment Counseling Program
Outcomes in the program are affected by uncontrolled factors in clients' lives, and by the reciprocal influence of those factors and the counseling program. This lack of control has several important implications for the research evaluation process.
First, according to the client-focused model on which this research is based (Kohlenberg & Goldblum, 2001), finding fulltime employment is an important, but not the exclusive outcome of the process. The program provides a guided consideration of the various factors that must be considered in making a plan that is appropriate to the individual's situation. Being employed may not--or not yet--be the best outcome for a particular client at that time. As one PWA put it, "I want to make the great decision to go back to a job and enjoy the world of the living, but I could be jumping from the frying pan into the fire." (Layne, 1997). A successful outcome is, therefore, an informed decision by the client that is based on an adequate process to support that decision. Outcomes are necessarily subject to modification as changes in the client's circumstances may require subsequent reconsideration. This range of client decisions means that each participant is expected to develop an appropriate plan for considering work, but that deficits or barriers in one or more of the four critical factors may mean that actual employment is still well in the future (Goldblum & Kohlenberg, 2001).
Second, because the program continues for eight weeks, developments in other life areas impinge upon the vocational outcomes of the participants. Though health is a major factor, it is only one factor affecting individuals' labor force participation (Yelin & Katz, 1994). In addition to medical developments, the vocational objectives of the program were clearly tied to financial/legal and psychosocial factors (Kohlenberg & Goldblum, 2001). Such recurring, interactive relationships are to be expected in a complex process of vocational counseling, particularly when the program is examined on a longitudinal basis (in the concluding discussion, the needs for large-scale longitudinal research are addressed).
Content of the Group Counseling Program The MAP groups' eight-week (16 hours) program included:
* assistance in self-determining members' physical capacity to work;
* interest and values testing and further exploration of values and goals;
* identification of barriers to employment in four inter-related areas (medical, financial/legal, psychosocial and vocational);
* test interpretation and counseling;
* referral to benefits counseling and other information sources and support groups;
* labor market information and assistance in deciding on a vocational goal;
* instruction on informational interviewing;
* instruction on researching labor market and training information related to the vocational goal;
* referral to other programs provided by the agency on resume writing, interviewing, legal rights, housing, debt and credit and career information; and
* referral to resources available in the community (including self-employment support, computer training, and local colleges) and resources available through the California Department of Rehabilitation.
The complexity of the program is a disadvantage from the perspective of strict experimental research design. The advantage is that it generally reflects sound counseling practices that meet client needs in a real setting and is more likely to reflect real operational practice. The elements that could be controlled with consistency--the core curriculum and manner of presentation--were maintained throughout the evaluation period.
Data and Methodology
Two forms of evaluation were conducted--a focus group that included nine volunteers from the original participants and an analysis of changes between pretest and posttest in:
* needs and concerns of the participants for vocational counseling services,
* client-perceived barriers to returning to work in three areas (vocational, psychosocial and legal/financial--specifically benefits counseling) areas, and
* areas where clients believed the group counseling process had produced changes in needs and concerns.
Study 1: The Focus Group
Procedures. All of the 67 participants in the five groups were invited to participate in the focus group. A brief questionnaire was used to gather quantitative information on their reactions to the program (to be used in curriculum revision) and to perceived changes in personal factors before and after participation. The instrument was designed to stimulate and guide subsequent discussion on postseminar changes that had occurred in the four factors of the Client-Focused model (medical, legal/financial, psychosocial and vocational). The sample size is small and unrepresentative, but the nonparametric tests were conducted to provide extra validation of information gathered in the focus group discussion.
Focus Group Results: Aggregate Change. The participants were asked to rate change in the four factors (represented by 13 separate items) since their participation in the program. Responses were elicited on a 5-point scale (the center point of "0" indicated no change, while -1 and -2 were "worse" and 1 or 2 indicated positive change.) Negative aggregate scores indicate a worsening, and positive scores indicate an improvement since participation in the program. Table 1 contains the aggregated responses.
Of the total of 117 individual responses (nine individuals on 13 items), roughly half (52) indicated no change in status. The least change was reported for medical side effects and anxiety. The greatest declines were reported for general health, energy/stamina, and financial status. The greatest positive changes experienced by the group were a decrease in hopelessness, increased activity level, and progress toward a vocational goal. The sample does not allow a conclusive statistical summary, but the quantitative data and the ensuing focus discussion indicate two major points: (a) the instability of the medical and financial factors are strongly interrelated with the vocational process, and (b) the group counseling process (and follow-up activities) can have a significant practical effect in increasing vocational and other activity and in improving the affective tone of the client (by decreasing hopelessness).
Focus Group Participants: Individual-Level Results. Even though the small size of the focus group does not allow for a detailed analysis of individual change factors, some useful indications are present. Non-parametric correlations showed two central clusters of change. The first is associated with the psychosocial state of the individual. Depression is a common problem in this population, as are anxiety and low activity levels. For the focus group the three variables clustered together--a reduction in depression was significantly related to reduction in anxiety (.63), and increase in activity (.71). The second major set of changes clustered around progress toward a vocational goal which was associated significantly with perceived improvement in benefits (.71), but also with moderate (but nonsignificant, given the small sample size) correlations with reduction of depression (.44), reduction of anxiety (.46), increase in hopefulness (.48), and improvement in the individual's financial situation (.41).
Study 2: Survey Results
All 67 participants filled out the pretest questionnaire at the beginning of their first group meeting. Posttest questionnaires were filled out at the end of the eighth meeting, if possible, or provided by mail follow-up. Of the 67 participants, 43 (64%) filled out the posttest questionnaire. Questionnaires elicited participants' responses in three areas: needs and concerns, perceived barriers to returning to work, and feelings.
Needs and Concerns: Before Group Counseling. Table 2 presents needs and concerns expressed by participants at the beginning of the program. Two columns of information are given. The first is a sample size of 43 that represents those for whom pretest and posttest data were available; the second is for the 24 participants for whom only pretest data were available. The difference between the two columns allows some estimate of the "bias" in availability of information. Those who completed both the pretest and posttests differed from those who did not complete the posttest. The strongest difference was that the latter group was somewhat more sure about their skills but also less sure about available jobs.
Initial MAP group concerns focused on the details of how to return to work and the issue of stress. Stress is one of the most common concerns reported by clients of the Positive Resource Center's Employment Services. The desire for meaning in work is significantly stronger than worry about specific issues regarding work capacity or impact on benefits. At the beginning of MAP, the group participants had more concerns about broader issues of values, career choice and stress than about the more specific issues of job availability or the effect of earnings on benefits.
The 24 participants who either did not complete the program or were unavailable for the posttest survey do not seem different from those who completed the program in most respects. There are some differences that seem worth monitoring in the future. The "noncompleters" seemed more sure about their skills and less certain about what jobs were available. Possibly, those who did not complete the program or were unavailable for the posttest follow-up were more uncertain about their place in the vocational process from the beginning.
Needs and Concerns: After Group Counseling. Table 3 shows the changes that occurred in needs and concerns from the beginning to the conclusion of the program. Two kinds of information are presented. The first shows percentage changes before and after the MAP program. The last column reports the significance test of a comparison of the means of scores (using a paired sample t-test).
The areas in which significant change took place are those in which a vocational counseling program should expect success. Participants showed a decreased need for career planning help, an increase in the personal knowledge needed to choose a suitable job, a major increase in knowledge of the labor market, and a stronger confidence about their job skills.
In other areas, initial concerns remained high and relatively unchanged by program participation. Stress remained a strong concern, as did the issue of finding meaningful work. Participants indicated concern about their basic physical ability to work at all and an ongoing need for help in choosing a career. Interestingly, some vocational concerns were not reduced and might even have been heightened; for example, the need for continuing help in "choosing the right job/career."
Perceived Barriers: Before and After the Group Counseling Program. Table 4 shows the barrier reduction that occurred during the course of the program. The last column reports the significance of a paired means t-test and is a conservative measure of whether the change observed should be considered statistically significant.
At the end of the program, there were three significant changes. Participants were more sure about what kind of job they wanted and more able to discuss work history gaps. They were also more aware of their need for benefits information and felt they needed more. Perceived barriers to work were reduced while the perceived need for more counseling and assistance increased.
There is evidence for some reduction in participants' need to acquire computer skills, update what skills they possessed, handle stress, and develop interviewing skills ("talking to employers"); however, the general level of those perceived needs remained high even after the program. Health concerns were roughly comparable before and after the program (unlike the focus group in which there was a reduction in perceived health status).
Affective Changes: Before and After Group Counseling. Participants were asked at the beginning and at the end of the program to record on a simple checklist the feelings they had about "going back to work." Table 5 displays the percentage of participants selecting each item.
Items displaying significant differences before and after the program were reductions in feelings of being unprepared, hesitant, and anxious. There were also reductions in feeling apprehensive, capable, stressed, and pressured, but these changes were not significant in the paired sample t-tests.
Anxiety and apprehension were the most prevalent feelings both before and after the program, though there was some evidence that both were reduced somewhat by the end of the program. The MAP group process seemed to make the most difference in helping participants feel prepared to take their next vocational steps, but had less influence on psychological issues that may be persistent among PWAs entering the "considering work" process.
Conclusions and Discussion
Group Counseling for People with HIV/AIDS
A closed counseling group of limited duration, with a program focused on increasing participants' awareness of the specific interrelated factors in making a decision about employment, can have a significant positive impact on those factors. This format can be an efficient way of conducting counseling, particular when staff resources are limited. Participation in the MAP program of group counseling was associated with
* reduction in vocational concerns,
* change in perception of barriers to employment,
* changes in participants' feelings in several areas (e.g., decreased feelings of being "unprepared" or "hesitant" about going back to work), and
* progress toward vocational goals.
Implications for Vocational Rehabilitation: Counseling PWAs
The MAP career counseling process helped most in addressing vocational concerns, although half of the participants remained uncertain about a job goal at the end of the process. Many people living with HIV see choosing the right vocational goal as essential. PWAs attach this importance to the vocational goal because they perceive jobs as a major cause of stress and they commonly associate stress with declines in health. PWAs live with a disease process in which very little is under their control. However, many PWAs do have the choice of whether and how to work and, therefore, they feel strongly that exercising what control they have is essential to both their physical and mental health. Making an incorrect vocational choice can have a major impact on their health.
Participants identified concerns about barriers to employment in all four interrelated factors. Within each factor, specific areas of concern were: financial/legal (benefits, medical insurance, income), psychosocial (anxiety, stress) and vocational (choosing the right job, fitting the job to one's values, interviewing, and acceptance by employers). Furthermore, although MAP groups did not focus on psychosocial issues specifically, the group process also affected this factor, with decreases in anxiety, hesitancy, and apprehension, and an increase in hopefulness.
These vocational rehabilitation results point to the utility of a group counseling program for people living with HIV/AIDS. The group format stimulates intensive "considering work" by combining the functions of (a) imparting cognitive knowledge of employment-related issues, (b) providing a supportive group environment for discussion of vocationally-relevant personal issues, and (c) dealing with perceived barriers to employment. The program also helps maximize counseling resources when the client load is high or counseling staff is limited. These benefits of group counseling do not obviate the need for individual counseling or other services, but they can help maximize the efficacy of staff resources. In fact, such a program can have the effect (as reported above) of sensitizing clients to other services they need on the way to considering work.
The data reported here are only a beginning in evaluating vocational programs for people with HIV/AIDS. While public and governmental interest in employment issues has increased with the advent of new medical treatments, empirical research on the actual process of vocational rehabilitation for this population is scarce. The next section suggests some research avenues that would provide much needed information for rehabilitation professionals.
Implications for Research
There are needs for (a) similar research on a more diverse population of PWAs, (b) replication in other settings, and (c) consideration of other disabilities for which this form of counseling might be appropriate. There are also broader theoretical and measurement issues implied by the Client-Focused Model.
The first need is to expand our conceptualization and measurement of the essential factors in the Client-Focused perspective. While this research contained measurement of perceived needs and barriers in each of four essential areas (vocational, financial/legal, medical and psychosocial), this measurement needs to be extended into the detailed aspects of each factor. A more comprehensive battery of subjective assessment items is currently being developed. In addition, more objective indicators of medical status, psychosocial support, and other factors need to be incorporated into the assessment.
The second need is to validate an instrument that can serve as a readily available instrument for client assessment. Experienced counselors already use these factors implicitly or explicitly in their work with clients, but having a validated assessment instrument could be a valuable tool. A validated assessment tool is needed not only for client self-assessment and initial counseling, but also for locating clients in the "considering work" process. Thus, a third research goal is to incorporate improved measurement of the four essential factors into a longitudinal study of the considering work process for a cohort of clients.
While it is well known that the individual's path toward some form of employment may be halting and irregular (reflecting the disease process itself), there is little systematic knowledge about how these factors interact over the long term. For many clients, a full return to paid employment will not be an option in the near future, though other valid pathways are open. Those pathways may include volunteer work, part-time employment, education and training programs, and self-employment. A narrow "return to work" approach focusing only on job placement may underestimate the importance of the alternative paths that are likely outcomes for PWAs. Maximization of client services and a better understanding of client outcomes require more systematic research that links a theoretically-driven assessment model with panel analysis of PWAs as they experience the "considering work" process over time.
Table 1 Aggregate Change in Key Concerns of Focus Group Participants Since Program Participation (n = 9) Item Worse Better How is your health in general? -5 Energy or stamina -4 How is your financial status? -4 Side effects from your medications -1 Anxiety 2 How are you feeling about yourself in general? 3 Depression 3 Support from family, school, AIDS service organizations 3 Support from physicians, therapists, psychologists 3 Benefits 3 Hopefulness 6 Involvement with activities 8 Progress toward a vocational goal 9 Note: Participants were asked: Please think about how you were doing while you were in the MAP group and how you are doing now. Then circle the line that indicates whether things have changed for you since you were in the group and whether they are better or worse. If things are the same, circle the middle mark. Scores are a sum of all participants' responses to the respective items. Table 2 Needs and Concerns at the Beginning of the MAP Group Rank Ordered (% "Strongly Agree" + % "Agree"). Comparison of Pretest/Posttest (N=43) with "Pretest Only" (N=24) Participants Need/Concern N = 43 N = 24 Difference I need help in planning the steps to go back to work 79% 75% -4 I am worried about the stress of going to work. 77% 83% 6 I want to find a more meaningful job 74% 79% 5 I need help in choosing the right job/career 63% 63% 0 I cannot do the job I used to do 58% 58% 0 I don't know what jobs would suit my personality. 54% 50% -4 I am not sure what my skills are 54% 42% -12 I don't know what jobs are available these days. 51% 63% 12 I don't know what happens to my income if I work. 33% 25% 8 I am uncertain about whether I can work at all. 24% 21% 3 Note: The sample of 43 participants are those who completed the pretest and posttest; the smaller group of 24 are participants who either dropped out of the program or for other reasons could not be reached for the posttest. Table 3 Change in Needs and Concerns Before and After the Group Counseling Program, Rank ordered by amount of change (N = 43), % "Strongly Agree" + % "Agree" Item Before After I need help in planning the steps to get back to work 79% 50% I don't know what jobs would suit my personality 54% 28% I don't know what jobs are available these days 51% 29% I am not sure what my skills are 54% 33% I am worried about the stress of going to work. 77% 74% I don't know what happens to my income if I work 33% 35% I want to find a more meaningful job 74% 77% I cannot do the job I used to do 58% 61% I am uncertain about whether I can work at all 24% 30% I need help in choosing the right job/career 63% 70% Item Change p I need help in planning the steps to get back to work -29 .01 I don't know what jobs would suit my personality -24 .00 I don't know what jobs are available these days -22 .00 I am not sure what my skills are -21 .01 I am worried about the stress of going to work. -3 .27 I don't know what happens to my income if I work 2 .64 I want to find a more meaningful job 3 .50 I cannot do the job I used to do 3 .69 I am uncertain about whether I can work at all 6 .90 I need help in choosing the right job/career 7 .40 Note: Significance is based on a paired samples t-test (see text for additional details). Table 4 Change in Perceived Barriers to Work Before and After MAP Rank ordered by amount of change (n = 43) Perceived Barrier to Work Before After Change p < I don't know what job I want 81% 54% -27 .00 I don't know how to deal with the gap in my work history 58% 40% -18 .01 I need computer skills 74% 65% -9 .21 My skills may not be up to date 81% 74% -7 .32 I could use help handling stress 61% 56% -5 .57 I have concerns about my health 67% 63% -4 .57 I am not used to talking to employers 47% 51% +4 .53 I need benefits information 26% 40% +14 .08 Note: Significance is based on a paired samples t-test (see text for additional details). Table 5 Feelings About Going Back to Work, Ranked by change in percentage "Yes" (N = 43) Item Pretest Posttest Change p < Unprepared 72% 49% -23 .00 Hesitant 81% 63% -18 .01 Anxious 84% 70% -14 .08 Apprehensive 79% 67% -12 .17 Capable 44% 33% -11 .17 Stressed 74% 65% -9 .25 Pressured 42% 33% -9 .21 Ready 12% 21% +9 .25 Note: Significance is based on a paired samples t-test. (see text for additional details)
The authors gratefully acknowledge the support and cooperation of Mark Misrok, Employment Services Program Manager, and the staff of the Positive Resource Center; Peter Goldblum of the AIDS Health Project of the University of California San Francisco for his partnership in the theoretical framework on the return to work process; Patrick McGinnis for his administrative support for the project; and the group participants whose cooperation, energy and forthrightness never ceased to impress us.
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Betty Kohlenberg Kohlenberg & Associates Meredith W. Watts University of Wisconsin-Milwaukee
Betty Kohlenberg MS, CRC, ABVE, Kohlenberg & Associates, Vocational Counseling Services, 1255 Post Street, Suite 943, San Francisco, CA 94109. Email: firstname.lastname@example.org
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|Author:||Watts, Meredith W.|
|Publication:||The Journal of Rehabilitation|
|Date:||Jan 1, 2003|
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