Abstract
BACKGROUND:
Students with intellectual and developmental disabilities lag behind their peers without disabilities when it comes to participation in college and employment. In response to this, researchers at Virginia Commonwealth University (VCU) created an online, six-week course for staff who work with students with disabilities in inclusive postsecondary education (IPSE) programs.
OBJECTIVE:
To create a course and technical assistance (TA) based on implementing supported employment strategies through VCU’s ACE-IT in College model, using evidence-based employment practices. The course and TA were developed to increase the skills of IPSE program staff, as well as increase the number of paid internship opportunities for the students in their programs.
METHODS:
VCU staff offered a six-week training program, followed by yearlong technical assistance to college and university staff who implement inclusive postsecondary education programs. The researchers conducted a case study of one program and followed them through the course and their TA activities. Data examined were: facilitated discussion board responses, needs assessment results, meeting notes and case study notes, as well as goals and strategies they developed.
RESULTS:
Results indicate a need for more staff and funding, as well as university buy-in. The fidelity of implementation allowed researchers to make slight adjustments for future TA participants.
CONCLUSION:
One participating program emerged as a case study site, and results indicate a need for more staff and funding. Detailed descriptions and technical assistant support strategies are provided, as well as implications for further research.
Keywords
Introduction
Higher education is a known pathway to careers for individuals with disabilities (Grigal et al., 2019) and can increase opportunities for youth with intellectual and developmental disabilities (IDD) (Thoma et al., 2012; Wehman et al., 2018). Higher education can be the impetus for personal and financial benefits, particularly for people with IDD (Getzel, 2014). In fact, employment rates double when individuals with IDD attend any amount of college compared to individuals with only a high school diploma (Getzel, 2014). Increasing employment rates for individuals with IDD is critical, especially because this population has the highest unemployment rate in any disability category (National Core Indicators, 2021) and is the most impoverished compared to any other disability category (Winsor et al., 2021). However, data show that even though inclusive postsecondary education (IPSE) benefits students with IDD and taxpayers, postsecondary education is not often promoted as a pathway to employment (Cimera et al., 2018).
According to Think College, the national research and technical assistance center for improving higher education for individuals with IDD, IPSE programs focus on creating a pathway to higher education for students with IDD through college-level courses and other activities (i.e., employment, clubs, events). There are over 300 IPSE programs that exist in the United States (Think College, n.d.). To create and expand IPSE programs, the Model Comprehensive Transition and Postsecondary Programs for Students with Intellectual Disabilities (TPSID) provides funding to increase programs across the country. TPSID programs must meet various criteria, including providing the opportunity for integrated work experiences (US Department of Education, 2015). The most recent outcome results from the TPSID Annual Report (Think College, 2021) reveal continuing issues in creating these pathways for long-term employment for students with IDD.
Yet, Think College reports that 67% of TPSID graduates remain employed three years after leaving the program. This employment rate is an improvement from what Grigal and colleagues previously reported in 2018, where only 36% had paid employment 90 days post-exit. This improvement is positive in light of the fact that 79% of TPSID programs reported that COVID-19 impacted at least one course during this cohort. The COVID-19 pandemic also affected work-based learning experiences –45% of students were not able to have a work-based learning experience, specifically because of COVID-19.
Obtaining further education beyond high school is viewed as a necessary step for gaining long-term economic outcomes (Madaus et al., 2014). The importance of IPSE for students with IDD has resulted in significantly higher earnings than those who did not receive college training (O’Neil et al., 2015). While advanced learning is associated with improved outcomes for all individuals, the impact of higher education on individuals with disabilities is particularly evident (Miller et al., 2019).
Purpose of the study
The importance of a higher education experience ultimately leading to a career for individuals with IDD cannot be overstated. Though over 300 IPSE programs exist in the US, the level of inclusion can vary among programs. For example, according to the 2020-2021 TPSID Annual Report released by Think College, 47% of students enrolled in current TPSID-funded programs have had at least one paid job or work-based learning experience. That means more than half of the students did not have any paid employment. Out of the 47%, only 66% of the work-based learning experiences were paid at or above minimum wage, while 34% were paid below minimum wage. Knowing the impact of higher education on employment, a systematic literature review was conducted on how employment supports are provided in IPSE programs. The current literature primarily focuses on employment strategies (e.g., Lindstrom et al., 2009; Gilmore, 2002; Wehman et al., 2018), but none directly applied using these strategies for students with IDD in college. It became apparent that additional research was needed on the use of strategies, in particular, supported employment, in IPSE programs to assist personnel in increasing paid employment opportunities for college students with IDD.
This article draws from a study that was conducted to determine the effects of trained personnel providing employment support in IPSE programs on paid employment experiences of students with IDD. The research team designed the study based on their experience implementing an IPSE program, ACE-IT in College (ACE-IT), as part of the first TPSID cohort in 2010. ACE-IT uses evidence-based practices incorporating the standards for IPSE programs established by Think College, and the standards for supported employment by the Association of People Supporting Employment First.
Students in ACE-IT adhere to course requirements and audit a variety of required and elective courses with other VCU students. Students receive in-class and out-of-class support from academic coaches. Additional academic supports include academic advisors, the Student Accessibility and Education Office, the writing center, and professors. One of the critical elements of ACE-IT, which was established at the beginning of the program’s implementation, was that every student would maintain paid employment and receive support from trained job coaches. During the three semesters of academics, students work on campus in part-time paid employment positions. During their final semester, the students transition into an internship in their career choice. ACE-IT has a 100% paid employment rate for students while in the program (earning minimum wage or above), and a 90% employment rate post-graduation.
Method
In 2019, VCU was awarded a five-year grant to establish a Rehabilitation Research and Training Center (RRTC) on Employment of Transition-Age Youth with Disabilities. One of the Center’s research studies focused on IPSE programs and paid employment while in college and post-graduation. The research study was designed to examine the effects of implementing an online course focusing on supported employment (SE) and its use in higher education, coupled with technical assistance for college personnel providing employment supports. The online course was built on the phases of SE, which members of the research team have adapted and tested through the ACE-IT in College program. The online course focused on the phases of SE including 1) getting to know the student, 2) job development and matching, 3) training and support, and job retention (Schall et al., 2015; Wehman et al., 2012).
The study was originally a quasi-experimental design (QED) within an Implementation Science model (Fixsen et al., 2005), with approximately one-half of the participants in the control group (those not choosing to receive technical assistance) and the other half in the experimental group (those choosing to receive technical assistance). Once participants complete the six-week course, they are asked if they would like to engage in one year of technical assistance (TA). Those who choose to participate receive a Needs Assessment rubric (Appendix 1). The Needs Assessment asks the potential participant to indicate their strengths and needs in their current college program and the career development activities they provide to their students with IDD. Regardless of accepting the TA, the intent of providing the online course is for participants to obtain information and resources on providing employment supports to college students that assist them in finding paid work experiences and/or paid internship opportunities. The research study members also used the CDC’s Replicating Effective Programs (REP) framework to develop the research questions and processes. The REP framework includes four components, which closely align with Fixsen’s Implementation Science model.
The first online course cohort started in the Spring of 2020, which coincided with the COVID-19 pandemic. Colleges across the United States had to either close or immediately switch to online instruction. This did not affect the study’s online attrition rate; however, because of the uncertainty of the time, potential participants did not sign up for the year-long TA as they had originally planned. The QED quickly became a case study design, with one model program. The research questions and methods for the case study are described below.
Research questions
The original research questions were modified for the case study design. The research team revised the study for the first year, and the protocol amendment was approved by the university’s Institutional Review Board (IRB).
RQ1: Which aspects of the online training and technical assistance were most instrumental in providing paid employment and/or paid internship opportunities for students with IDD while in college?
RQ2: What are the employment outcomes for students with IDD post-graduation who participated in paid employment and/or paid internship opportunities?
The research team also examined the fidelity of implementation to ensure the online course and technical assistance procedures were followed according to the established protocol. The National Implementation Research Network, housed at UNC-Chapel Hill, provides comprehensive information and resources on implementation science (NIRN, 2019). In their review of the research on implementation, they found positive correlations between fidelity and outcomes. In addition, studies showed that more changes to the program had adverse effects –while modifications should be made based on contextual factors, significant deviations from the original program negatively affected outcomes. Franks and Schroeder (2013) state in their presentation that implementation does not measure the outcomes of evidence-based practice; rather, it measures the process.
Research methods
The study protocol called for the following data sources to be used for the Cohort 1 case study.
The case study participant took the course in spring 2020 and implementation of the technical assistance started in October 2020. The activities for this single case study occurred through October 2021. The evaluator was able to begin case study activities immediately. In addition to all activities listed under “Document Review” in Table 1, the evaluator reviewed the case notes.
Sources and description of data reviewed
Sources and description of data reviewed
The participating inclusive post-secondary education program started because the university received a TPSID grant. The IPSE program is located in a southern state and focuses on students with intellectual disabilities. They are housed in the main university’s College of Education and Human Development as part of counseling and psychological services. The program focuses on preparing students for meaningful work within the arts and creative media-related fields. Alongside college courses in these areas, students participate in apprenticeships (as defined by participants), working directly with people in their field of interests, learning basic and intermediate-level skills, as well as creating portfolios, resumes, and other job-seeking tools. Students also participate in at least one on-campus internship in radio, news, magazine, theater, marketing, athletics, etc. Students are also connected to community-based unpaid internships and job opportunities upon completion of the two-year program. The program has been in existence since 2016.
The case study program has two employees who coordinate student activities. The program manager (Spenser) was the only staff member from their school enrolled in VCU’s online course. After the course ended, Spenser shared resources and materials with the second staff member. Both staff members participated in the TA. The asynchronous course lasted for six weeks. The online course required participants to watch instructional videos, review documents, complete a quiz each week, and post in a facilitated discussion board.
Review of facilitated discussion board entries
Course participants responded to a specific prompt in the discussion board each week that aligned with course content from that week’s lesson. The following paragraphs include an overview of each weekly topic and a summary of Spenser’s discussion posts.
In the first week of the course, participants reviewed videos and required materials about career development standards for IPSE programs and quality indicators that make a high-quality SE program. Per the discussion board prompt for the week, participants were to provide an overview of their program and select one quality indicator for IPSE programs (Grigal et al., 2012) or one quality indicator for SE programs (APSE, 2010) that needs priority attention for improving their own IPSE program. Spenser reflected on her hopes for the 6-week course and stated that she would like to work on “personalized job development and relationship marketing, utilizing personal networking,” which is an Association of People Supporting Employment First (APSE) SE competency. Spenser chose this competency to learn how to connect with families and social networks so that they can use familiar resources and connections.
In week two, course participants learned about the importance and process of getting to know each student, how to use person-centered planning in higher education, and updating career plans. Discussion board posts were to include a description of how program staff assess students’ abilities, interests, preferences, conditions for success, and support needs. Additionally, participants described how they will implement materials or change practices as a result of the information they reviewed this week. Spenser shared that her team works with their students (1:1 meetings, interviews, etc.) to gather information about interests, abilities, preferences, support needs, and conditions for success. Spenser emphasized the importance of work experiences and shared that as a result of this week’s lesson, she wanted to focus on having students experience several work opportunities to increase their exposure to different employment settings and be able to figure out what they liked best.
In week three, the course focused on job development. Participants gained information on networking, marketing, and other job development strategies. In this week’s discussion post, participants developed their own “elevator pitch” to market their program. Participants then shared other strategies from this week’s lesson that they might use to secure a placement. Spenser reflected on current practices and noted that she could tweak marketing materials for different audiences (i.e., employers, potential partners). Spenser described her elevator pitch to employers, which would include a description of the program, the program’s interest in collaborating with organizations/employers who would like to support students through an internship, information about supports provided through the program (i.e., job coach, peer mentor), and that the employment needs to be paid.
Week four included a review of the customized employment. Per the discussion board, participants were to share experiences with customized employment and how they might implement these strategies in their programs. Spenser shared that customized employment can be time-consuming and requires a great deal of effective communication. However, Spenser recognized that her program needs help with negotiating payment. Spenser mentioned that the employers indicate that they have budgeting constraints; however, they are more than willing to accept the student’s help at no cost. Spenser mentioned that not paying her students resulted in the view of the employers not valuing the position or the work.
In week five, participants learned about jobsite training, the critical role job coaches play, best practices for providing instruction during jobsite training, and strategies to create a fading plan (when the job coach starts to fade out). The discussion post had participants share their own jobsite training practices, how they can improve them, and their experiences with jobsite fading. Spenser expressed that she wanted to formalize their jobsite training practices and would be working on this during the upcoming academic year. Spenser also shared a success story about fading supports on a jobsite and how this experience exhibited the student’s independence on the jobsite. In fact, at the time of the discussion, the student still worked at the job independently, and the jobsite continued to be a resource for the program.
Finally, in week six, participants learned about the transition needs of students graduating from college, the practice of developing a transition checklist to prepare students for employment beyond the program, and how to implement follow-up procedures. This week’s discussion board prompt focused on transitioning students from college to their careers. Spenser described implementing a two-year program model completely focused on college to career. Spenser would like to concentrate on increasing job development and job shadowing experiences, building skills, and making connections with potential employment sites. Spenser also mentioned their current follow-up procedure that includes following up with their graduates by sending out a survey 60 days after graduation.
Review of technical assistance
The technical assistance with a member of the VCU research team began soon after the conclusion of the course, with the first meeting in October 2020. The TA protocol consisted of participants completing the Needs Assessment to determine areas of focus for the year-long TA; completion of an Action Plan; monthly check-in meetings for 12 months, mostly through Zoom, with occasional email updates, when feasible; and completion of tasks (tasks are set based on Needs Assessment results, as well as discussions during monthly meetings). An overview of the Action Plan, monthly meetings, and the TA instructor case notes follows.
Action plan
The VCU staff member, in conjunction with program team members, developed the action plan. The team had a measurable goal of increasing their knowledge and skills in job development for paid employment. At the conclusion of the TA, 50% of their students and alumni obtained paid employment in either off-campus or on-campus jobs. The objectives they chose to focus on for the year coincided with where the university saw its areas of opportunity to improve. They chose 11 strategies and activities to reach their goal, as shown in Table 2.
Goals and strategies to reach goals set by TA participant
Goals and strategies to reach goals set by TA participant
Each strategy was assigned to the name of the person responsible, as well as how VCU staff would assist or provide materials and resources. The strategies also had a timeline associated, which could be used in subsequent years (i.e., by the end of the semester; completed each semester; etc.), as well as the outcomes. Examples of those outcomes were phone and email scripts, best practices documents, a list of campus employers, and paid employment opportunities.
Over the course of the year, eight meetings took place over Zoom, with the additional four months being email updates. Supplemental materials were provided by the assigned VCU staff member via email each month in addition to the Zoom meetings. The first meeting consisted of introductions, overview of TA and expectations, review of their needs, setting of goals, and setting up the Action Plan (Appendix 2). The remainder of the meetings all began with giving updates and a review of tasks completed and ended with action items for the following month. Each monthly meeting or email update consisted of discussion of the components and tasks that were completed by the program staff members. The topics discussed included their currently enrolled students in detail; how they made connections with the business community; the pitch they developed to potential employers; new employers they want to target; and new internship leads.
Case notes
The VCU staff member providing TA entered case notes after each communication exchange with the university. Case notes included information about the time spent with the participant, the overarching employment topic (based on the course topics), the method of communication (video call, email), specific tasks and activities completed during the contact, tasks assigned for the next meeting, strategies or supports that worked for the participant, and any other relevant information. On average, the time spent with the participating program staff at each monthly meeting was approximately one hour, which included communication via email. Based on participant needs, the focus of meetings was either job development or customized employment.
Specific tasks completed during meetings each month included sharing resources and materials; a review and update on current students in the program; drafting emails and creating pitches for potential employers; and developing their Action Plan. Examples of some of the tasks assigned for the program staff to complete between meetings included completing the Action Plan, brainstorming current campus partners and future partners, completing data/information tracking spreadsheet, beginning data collection on students, completing data on students and sending emails to potential employers. VCU staff provided supports, interventions, and strategies during the TA. Some examples used were: providing templates for the process (i.e., staff training presentations, job development emails, meeting agendas, Google Drive organization); providing spreadsheets to collect data (i.e., tracking data and advice on filling it out, campus partners and contact information); and providing supportive advice (i.e., completing the Action Plan in small steps, targeting job sites for different students, and reminding them that paid employment is the goal).
Finally, the VCU staff member added any other relevant information or activity that occurred each month. Items here included students who have paid employment and their pay rate; participant requests to move to email updates for a period; changes in staffing and leadership of the program; and scheduling a meeting specifically to discuss program sustainability.
Findings
The findings and outcomes of the technical assistance were analyzed using the study’s research questions. The questions and findings are summarized below.
RQ1
Which aspects of the online training and technical assistance were most instrumental in providing paid employment and/or paid internship opportunities for students with IDD while in college? Hypothesis: Most helpful aspects are: increasing skills in providing supported employment, technical support on establishing on-campus employment, and working with employers.
The online training was developed to cover all aspects of providing supported employment, from getting to know the student all the way to student independence on the job, and not just those listed in the hypothesis. The TA serves the individual needs of the program, and it serves to build on the skillset of the university program staff. This particular program wanted to focus on Job Development and Customized Employment, which entails establishing on-campus employment, as well as working with employers. As evidenced in the monthly meeting notes, the program staff made a list of potential on-campus employers. They also focused on language to use with employers during face-to-face meetings, as well as emails. The two program staff members were able to establish a process using the templates and checklists, which they felt were extremely useful. Staff connected with potential employers, using the language they developed during the TA, and responses were positive. The program staff were able to convert a position that had traditionally been an unpaid internship into paid employment, as a direct result of the TA.
RQ2
What are the employment outcomes for students with IDD post-graduation who participated in paid employment and/or paid internship opportunities? Hypothesis: Students with IDD who participated in paid employment and/or paid internship opportunities will have greater employment opportunities after graduation as compared to outcomes of TPSID.
Data for this research question are still being collected and are not available at this time.
Fidelity of implementation
The VCU research staff member was responsible for ensuring the fidelity of implementation for the yearlong TA. Participants had to complete the course in a certain amount of time prior to starting the TA. During the planning phase, VCU TA provider and program staff discussed the key activities. Those were to: (1) touch base, at a minimum, each month; (2) create a monthly agenda template (Appendix 3); (3) plan TA activities based on the needs assessment; and (4) provide resources as needed.
The VCU research team member did not meet with case study program staff every month via Zoom; however, she did meet with them most months throughout the year. When program staff requested email contact due to their workload, the VCU research staff member made sure to touch base via email to ensure the program staff was making progress toward their goals. For example, the program staff requested an email update for February 2021. During the previous month’s Zoom meeting, the group reviewed a spreadsheet. For the February update, the program staff had begun to enter the data into the spreadsheet, which they found helpful.
The VCU staff member emphasized the importance of creating a meeting agenda template and adhering to it. This saved program staff members time in preparing for each meeting. The Action Plan also outlined the TA activities, which were based on their needs assessment. This helped them plan their work over the entire year. Finally, the research staff member provided multiple resources at every meeting and check-in.
Discussion
The purpose of the case study was to review the effectiveness of training program staff on SE practices. Through data collection and analysis important topics of discussion emerged.
Sustainability of programs
Think College’s standards, quality indicators, and benchmarks (Grigal et al., 2012) continue to serve as the gold standard for quality IPSE programs. Three standards in particular are extremely relevant in terms of the sustainability of programs: standard 5, alignment with college systems and practices; standard 6, coordination and collaboration; and standard 7, sustainability. This study confirms the importance of Think College standards, quality indicators, and benchmarks relevant to sustainability of programs and contributes additional considerations.
Staffing needs
IPSE programs offer a variety of academic, employment, and social opportunities for students with IDD. Though programs often vary in structure in accordance with their universities and needs, it is undeniable how beneficial IPSE is for students and universities. Students who graduate from IPSE programs have higher earnings (O’Neil et al., 2015), improved overall outcomes (Miller et al., 2019), and opportunity to grow self-determination skills and advocacy (Thomas et al., 2020). A major aspect of ensuring access to opportunities in IPSE programs that became apparent through this case study is having programs with sufficient staff.
Throughout the analysis of documents, it became apparent that an important part of training program staff of IDEAL was the sheer number of program staff. At IDEAL there were two program staff that were responsible for implementing SE practices: the program manager and the part-time employment staff member. Throughout the year of TA, Spenser and the VCU staff remained in continuous communication. They originally created a meeting schedule to meet once a month for the entire year. As the year of TA went on, Spenser requested fewer Zoom meetings. Spenser communicated that she was overwhelmed by her responsibilities. When the VCU staff suggested email check-ins for a couple months, Spenser was relieved. Together they decided that email check-ins would reduce the number of responsibilities and provide enough support to meet IDEAL’s goals. VCU staff continued to share resources, create programmatic supports (e.g., email templates to use when emailing a potential employer), and provide encouragement. For IDEAL, TA needed to be flexible to meet their staffing needs.
Though not all IPSE programs are structured the same way, all IPSE programs do emphasize employment (Thomas et al., 2020). To provide SE, the evidence-based practice used with individuals with IDD to access and maintain employment, programs must have available staff. However, the sheer number of program staff is a known barrier in IPSE programs (Rooney-Kron et al., 2022). As programs continue to grow and evolve with the ever changing college climate, program staff needs growth in both numbers and training.
Funding
An important element of program infrastructure is the financial sustainability of the program. IPSE programs that begin as TPSID programs face challenges when it comes time to diversifying their funding beyond the grant (Grigal et al., 2013). Diversifying funding became an apparent issue for IDEAL as they learned to navigate funding beyond the TPSID grant.
Sustainability was a significant concern for Spenser and was continuously brought up in monthly meetings, even though it was not a topic on the agenda. To address Spenser’s concerns, VCU staff added a new topic to their action plan: sustainability. VCU staff modified the meeting schedule to strategize a plan for sustainability. In this meeting Spenser shared concerns about the sustainability of the program and emphasized the insecurity of funding for staff positions. It seemed as though the longevity of the entire program rested on Spenser’s shoulders. Spenser mentioned the disconnect she felt from the university at times and how she felt alone in navigating funding options. In this meeting, a plan was created to market the program, establish a connection to leadership at the university, and develop fundraising strategies. VCU staff strategized concrete plans to target integration into the university while simultaneously marketing the benefits of the IPSE program to leaders and other stakeholders.
Funding issues are a barrier to sustaining IPSE programs (Plotner & Marshall, 2015). Some programs create advisory boards to help navigate the community, explore funding options, and market the program (Grigal et al., 2013), but not all programs have the training and resources to conduct such efforts. Thus, creating training and resources for sustainability is a pathway to maintaining and growing IPSE programs.
University buy-in
Collaboration with universities and their faculty and staff allows students in IPSE programs to access resources and services available to them. In fact, one of the quality indicators of an IPSE is establishing this connection so students can access services from financial aid, disability services, and both academic and career advice (Grigal et al., 2012). Establishing a connection is mutually beneficial for students, so they can access resources, and for the program as a whole, so the program can become enmeshed within the university.
When collaboration becomes a challenge within a university, IPSE students inevitably miss out on opportunities. For example, in the last month of TA, IDEAL staff and VCU celebrated IDEAL meeting their goal of securing paid employment for one of their two first-year students. Shortly after their meeting concluded, Spenser reached out to alert VCU staff that funding fell through for the secured placement. Spenser surmised the sudden lack of funding was due to minimal understanding about the distribution of funds to college students with IDD from the financial aid office.
IDEAL, like ACE-IT, is a Comprehensive Transition and Postsecondary (CTP) Program for students with IDD. In accordance with the Higher Education Opportunity Act (HEOA), students with IDD that are enrolled in a CTP are eligible to receive the Federal Pell Grant, Federal Work-Study Grants, and Federal Supplemental Educational Opportunity Grants. Though Spenser had discussed IDEAL’s CTP status with the financial aid office, there were unanswered questions and a lack of understanding regarding federal work study. University buy-in is directly related to the overall sustainability of IPSE programs. It is often the role of IPSE staff to advocate for access to resources, such as financial aid, which can determine the retention of students and the overall sustainability of IPSE programs.
Conclusion
This case study provides an in-depth understanding of some of the day-to-day challenges faced by IPSE programs to implement meaningful employment opportunities on their campus. The review of the documents from all course participants, as well as the in-depth review of the case study participant revealed some of the realities faced by these programs. While the staff were able to meet their goals throughout the year of TA, challenges surfaced. Staff numbers to run these programs are low, as is the funding to keep these positions. Additionally, there is increasing attention on the need for strategies, training, and support to assist program personnel in offering employment-related experiences for college students with IDD as an integral part of their program (e.g. Grigal et al., 2019; Domin et al., 2020; & Scheef, 2019). Multiple research methods, including the use of case studies, are needed to gain an understanding of the issues, challenges, and successes at the program level to prepare these college students for employment, and ultimately their careers.
Footnotes
Acknowledgments
The authors would like to thank the case study participants, who also took the time to contribute to the writing of this article.
Conflict of interest
The authors report no conflict of interest.
Ethics statement
This study was approved by Virginia Commonwealth University’s Institutional Review Board (IRB HM20018783).
Funding
The content of this manuscript was developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (#90RTEM0002) and does not necessarily reflect the views of the funding agency.
Informed consent
All participants provided informed consent prior to their participation in the study.
