SPINAL CORD INJURY (SCI) results in immediate and

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1 588 ORIGINAL ARTICLE Stability of Vocational Interests After Recent Spinal Cord Injury: Comparisons Related to Sex and Race James S. Krause, PhD, Jillian M. Ricks, BS ABSTRACT. Krause JS, Ricks JM. Stability of vocational interests after recent spinal cord injury: comparisons related to sex and race. Arch Phys Med Rehabil 2012;93: Objective: To identify the stability of vocational interests first assessed during inpatient rehabilitation for spinal cord injury and again an average of days postinjury to determine the extent to which stability of interest varies as a function of race and sex. Design: Longitudinal. Setting: Data were collected at a specialty hospital. Participants: At enrollment, participants were a minimum of 16 years of age, were currently hospitalized for inpatient rehabilitation, were less than 6 months postinjury, had residual impairment after traumatic spinal cord injury, and were either white or black, and non-hispanic. Participants (N 304) were assessed an average SD of days after injury and again an average SD of days postinjury (averaged 785.1d between assessments). Interventions: Not applicable. Main Outcome Measure: The Strong Interest Inventory, a 317-item vocational interests measure. Results: A repeated-measures general linear model was used with 4 groups based on a combination of race and sex. Significant cohort by time interactions were observed on 4 general occupational themes (investigative, artistic, enterprising, and conventional). In nearly all cases, black women showed decreases in average interest scores compared with the other groups. There was a clear pattern of change in the direction of greater homogeneity of interests over time as measured by the range of theme scores between cohorts based on sex and race. Although changes in mean interest profiles varied as a function of sex and race, less consistent differences were observed when stability coefficients were the measure of change. Conclusions: The direction and degree of change in mean scores for vocational interests was related to sex and race. With the exception of black women, vocational interests increased from baseline to follow-up. Key Words: Employment; Occupations; Rehabilitation; Spinal cord injuries by the American Congress of Rehabilitation Medicine From the College of Health Professions, Medical University of South Carolina, Charleston, SC. Supported by the Department of Education (National Institute on Disability and Rehabilitation Research grant nos. H133N and H133G030151). Contents of this article do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to James S. Krause, PhD, Dept of Health Sciences and Research, 77 President St, Ste C101, MSC 700, Charleston, SC, krause@musc.edu. Reprints are not available from the author. In-press corrected proof published online on Feb 10, 2012, at /12/ $36.00/0 doi: /j.apmr SPINAL CORD INJURY (SCI) results in immediate and permanent changes in physical functioning that typically impedes ability to perform tasks. The extent to which SCI disrupts function is related to the neurologic level and neurologic completeness of injury. One of the primary areas in which participation is limited is vocational functioning, where employment rates typically do not exceed 30%. 1-3 Participation in other important activities of life may also be limited, resulting in diminished life satisfaction. 4,5 Vocational interests have been linked to vocational outcomes in the general population. 6 According to Holland s theory of vocational choice, there are 6 personality types and corresponding environments, abbreviated as RIASEC. The 6 types are Realistic (conservative, practical, like to work with their hands), Investigative (problem-solving, intellectual), Artistic (high degree of creativity, expressive, unconventional), Social (service-oriented, extroverted), Enterprising (businessoriented, persuasive, value social status), and Conventional (orderly, value technical proficiency). People will seek out environments allowing them to act on their interests. Congruence between interests and environments is critical to longterm employment stability. 7 After SCI, many types of interests may be difficult to act on due to the physical limitations of the injury. Early research suggested that the majority of individuals with SCI have interests within the Realistic theme, which reflects activities requiring physical strength and experience. 8,9 In fact, many SCIs are the result of engaging in high-risk activities consistent with the Realistic theme. Once established, these interest patterns are highly resistant to change. 10 More recent research using a larger and more diverse cohort, including a significant number of women and blacks, measured vocational interests during inpatient hospitalization and has challenged some of the earlier findings. 11 The interests of white men were predominantly on the Realistic theme, consistent with earlier research. However, the interests of women and blacks were substantially different. Women scored highest on Social, Enterprising, and Conventional themes. Black participants had significant elevations on the Social, Enterprising, and Conventional themes exceeding standardized norms. These findings are consistent with those of the general population. For instance, Kaufman et al 12 found that blacks scored higher on the Social, Enterprising, and Conventional themes, while whites scored higher on the Realistic and Investigative themes. On the Basic Interest Scale (BIS), whites scored higher on Nature, Agriculture, Adventure, Science, Medical Science, and Mechanical, and blacks scored higher on Religious, Sales, Public Speaking, Social Service, Law/Politics, Business Management, and Office Practices. BIS GOT SCI SII List of Abbreviations Basic Interest Scale General Occupational Theme spinal cord injury Strong Interest Inventory

2 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause 589 The only longitudinal study reported in the literature identified the stability of interest over an 11-year period. 10 Participants in this study averaged 9 years postinjury at enrollment (a follow-up to the study reported by Rohe and Athelstan 9 in 1985). Interests changed very little over the 11-year follow-up, even when they reflected the Realistic theme and activities incompatible with SCI. However, given the lengthy interval of time since injury, interests could have changed substantially prior to the initial assessment. There are significant gaps in the literature of vocational interests after SCI. Whereas earlier studies suggest that vocational interests are focused within a single theme, indicative of an interest in highly physical tasks, and resistant to change, more recent research challenges these findings. It appears that, when first measured shortly after SCI onset, diverse patterns of interests are observed that vary across sex and race. The only longitudinal study used almost exclusively white men enrolled an average of 9 years postinjury, leaving open to question its generalizability to other groups. The purpose of this study was to identify stability of vocational interests after SCI for cohorts of participants broken down according to race and sex. There were 2 primary research questions: (1) To what extent will mean scores on the General Occupational Theme (GOT) and BIS from the Strong Interest Inventory (SII) change over the first 2.5 years postinjury as a function of race and sex? (2) To what extent will interests change as a function of sex and race, as measured by stability coefficients (ie, the extent to which the same people will be high or low on any given scale)? METHODS Participants Institutional review board approval was obtained prior to initiating data collection. Participants were enrolled between January 2002 and September 2006 from a specialty hospital in the Southeastern United States. The eligibility criteria were as follows: (1) traumatic SCI, (2) currently hospitalized, (3) minimum of 16 years of age at assessment, (4) some residual deficits, and (5) assessed within first 6 months after onset. An additional criterion was added for the current analysis the participant must have been either white or black and of non- Hispanic origin. There were 499 participants meeting these criteria who completed materials during inpatient rehabilitation an average SD of days after SCI onset (range, 2 153d). Three hundred four participants completed a second assessment an average SD of days later (range, d). Procedures During initial data collection, the SCI peer support coordinator approached new patients to request participation and obtain informed consent. A staff member subsequently met with the participant and either helped to complete the questionnaire or left the questionnaire for those who did not need assistance. Participants were given $25 remuneration. Two follow-ups were conducted. The first was restricted to approximately 70% of the initial sample and was initiated approximately 12 months after hospital discharge. Participants again received $25 remuneration. The second follow-up was initiated approximately 1 year later. For the second follow-up, we were able to solicit participation from all those who completed baseline materials. Remuneration for the second follow-up was $50. Of the original 499 participants, 304 returned completed materials on 1 of the 2 follow-ups and 195 responded to neither follow-up. For those who completed both follow-ups (n 135), we used that with the greatest interval of time between assessments. All data were entered and verified to ensure accuracy. Measures The 1994 edition of the SII, Form T317, was used. 13,14 Specifically, we are reporting changes in scores on the 6 GOTs, 25 BISs, and the 4 special scales. The GOTs were derived from the Holland vocational typology and include the 6 components of the hexagonal RIASEC model. The 25 BISs are composed of homogeneous items, and each is categorized within 1 of the GOTs. Each scale was developed to have a mean of 50 and an SD of 10. We also used the 4 special scales including Work style, Learning environment, Leadership style, and Risk taking/ Adventure. The median 3- to 6-month test-retest stability coefficient from a sample of employed adults on the GOT is.89 and on the BIS is Scale scores are based on comparisons with sex-specific normative groups, the men s general reference sample and the women s general reference sample. Therefore, sex-based comparisons of scores between men and women reflect how the samples of men and women differ from each other relative to their normative groups. The men s general reference sample averages 44.6 years of age, is 8.3% nonwhite, and shows that 5% have a disability. The women s general reference sample averages 40.5 years of age, is 8.5% nonwhite, and shows that 2.9% have a disability. Statistical Analysis Descriptive statistics were used to summarize the characteristics of the study sample and scores on the SII. We then identified the extent to which attrition was selective by comparing those who did not respond to follow-up with those who did respond. We compared them on baseline demographic, injury, and GOT scores. We used the chi-square statistic for categorical variables and t tests for continuous variables. A repeated-measures general linear model was used to analyze changes in scale scores over time. There were 2 withinsubjects effects: the time effect and the cohort by time interaction. The between-subjects effect was for the cohorts. The cohort was identified by forming 4 groups based on the combination of race and sex: white men, white women, black men, and black women. We used 4 groups rather than 2 independent cohort variables, race and sex, due to sample size limitations and the instability of higher-order interaction effects between 2 cohort variables and the time variable. Stability coefficients were also generated and presented for each of the 4 cohorts and for the full sample. RESULTS Participant Characteristics The breakdown by race and sex was as follows: white men (55.6%), white women (21.7%), black men (18.1%), and black women (4.6%). Slightly less than half of the participants reported cervical injuries (48.0%). The average age at injury SD was years. At the time of injury, 4% had a master s degree or higher, 13.2% had a 4-year degree, 79.9% had a high school certificate or general equivalency degree, and 20.1% had not completed high school. At the time of injury, 76.7% were working. Attrition Analysis We classified participants as to whether they had completed a follow-up assessment. Respondents to 2 assessments were

3 590 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause more likely to have more years of education (12.9 vs 12.1). A higher proportion of women participated at follow-up (76.2% vs 56.9% of men). Similarly, a higher proportion of whites (65.1%) participated in a follow-up as compared with blacks (50.0%). No differences were noted for injury level or etiology. Additionally, significant differences were noted on only 1 GOT (Investigative), where nonrespondents reported higher scores. Changes in Interest Over Time Cohort by time interactions were significant for 4 of the 6 GOTs (all except Realistic and Social), whereas none of the main effects for time were significant (table 1). On each of the GOTs for which a significant interaction was observed, the range of difference in the means between the 4 groups in the cohort decreased between baseline and follow-up. For instance, for the Investigative theme, the scores ranged from 38.4 (white women) to 46.6 (black women) at baseline, with follow-up scores only ranging between 42.4 (black women) to 44.8 (white men). Similarly, the scores of black women declined on each of the 4 scales, whereas they increased, at least minimally, for each of the other 3 groups. There were no significant main effects for time on the BIS (table 2). Significant cohort by time interactions were also observed for 16 of the 25 BISs, including Nature, Military, Athletic, Science, Mathematics, Medical Science, Music/ Drama, Art, Applied arts, Writing, Social services, Public Speaking, Law/Politics, Merchandising, Computer activities, and Office services. For the most part, the pattern was similar to that of the GOT, with some noteworthy differences. For instance, for the Nature scale, both black men and black women reported declines, whereas white men and white women reported increases. For Athletics, the primary decline was for black men. Science, Mathematics, Music/Drama, and Computer skills also showed declines for both black men and black women, although the declines for black men were much smaller. There was a significant main effect for 1 of the special scales (Risk taking/adventure) (see table 2) where each cohort reported Table 1: Scores on the GOTs as a Function of Time, the Cohort by Time Interaction, and the Cohort Effects Within-Subjects Effects Between-Subjects Effects Baseline Follow-Up Time Cohort Time Cohort Scale Mean SD Mean SD Mean Difference F F F Realistic * W-Man B-Man W-Woman B-Woman Total Investigative W-Man B-Man W-Woman B-Woman Total Artistic * W-Man B-Man W-Woman B-Woman Total Social * W-Man B-Man W-Woman B-Woman Total Enterprising * W-Man B-Man W-Woman B-Woman Total Conventional * W-Man B-Man W-Woman B-Woman Total Abbreviations: B, black; Cohort Time, the interaction term between the race/sex categories and time; F, F value from analysis of variance test; W, white. *P.001; P.01; P.05.

4 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause 591 Table 2: Scores on the BISs and Special Scales as a Function of Time, the Cohort by Time Interaction, and the Cohort Effects Within-Subjects Effects Between-Subjects Effects Baseline Follow-Up Time Cohort Time Cohort Scale Mean SD Mean SD Mean Difference F F F Agriculture * W-Man B-Man W-Woman B-Woman Total Nature * W-Man B-Man W-Woman B-Woman Total Military W-Man B-Man W-Woman B-Woman Total Athletic * W-Man B-Man W-Woman B-Woman Total Mechanical activities * W-Man B-Man W-Woman B-Woman Total Science * 2.88 W-Man B-Man W-Woman B-Woman Total Mathematics W-Man B-Man W-Woman B-Woman Total Medical Science W-Man B-Man W-Woman B-Woman Total Music/Drama * W-Man B-Man W-Woman B-Woman Total Art * W-Man B-Man W-Woman B-Woman Total

5 592 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause Table 2 (Cont d): Scores on the BISs and Special Scales as a Function of Time, the Cohort by Time Interaction, and the Cohort Effects Within-Subjects Effects Between-Subjects Effects Baseline Follow-Up Time Cohort Time Cohort Scale Mean SD Mean SD Mean Difference F F F Applied arts W-Man B-Man W-Woman B-Woman Total Writing * 15.64* W-Man B-Man W-Woman B-Woman Total Culinary arts * W-Man B-Man W-Woman B-Woman Total Teaching * W-Man B-Man W-Woman B-Woman Total Social services * W-Man B-Man W-Woman B-Woman Total Medical service * W-Man B-Man W-Woman B-Woman Total Religious activities * W-Man B-Man W-Woman B-Woman Total Public Speaking * W-Man B-Man W-Woman B-Woman Total Law/Politics W-Man B-Man W-Woman B-Woman Total Merchandising * W-Man B-Man W-Woman B-Woman Total

6 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause 593 Table 2 (Cont d): Scores on the BISs and Special Scales as a Function of Time, the Cohort by Time Interaction, and the Cohort Effects Within-Subjects Effects Between-Subjects Effects Baseline Follow-Up Time Cohort Time Cohort Scale Mean SD Mean SD Mean Difference F F F Sales W-Man B-Man W-Woman B-Woman Total Organizing/management * W-Man B-Man W-Woman B-Woman Total Data management * W-Man B-Man W-Woman B-Woman Total Computer activities * W-Man B-Man W-Woman B-Woman Total Office services * 34.82* W-Man B-Man W-Woman B-Woman Total Work style * W-Man B-Man W-Woman B-Woman Total Learning environment W-Man B-Man W-Woman B-Woman Total Leadership style W-Man B-Man W-Woman B-Woman Total Risk taking/adventure * W-Man B-Man W-Woman B-Woman Total Abbreviations: B, black; Cohort Time, the interaction term between the race-sex categories and time; F, F value from analysis of variance test; W, white. *P.001; P.01; P.05.

7 594 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause at least minimal gains. There was also a significant interaction effect for Learning environment. Declines were reported by black women, whereas other cohorts reported increases. Stability Coefficients The average stability coefficients for the GOT ranged from a low of.35 (black men) to a high of.61 (white women) with.57 across the full sample (table 3). The average for black women was.45. A similar pattern was observed for the BIS, as black men reported the lowest average coefficient (.35), followed by black women (.51), white men (.57), and white women (.59). The variation for special scales was somewhat smaller, ranging from.50 to.69, with the lowest coefficients again observed for black men and the highest coefficients for white women. DISCUSSION Several key findings emerged from this study, the most interesting of which was the tendency for follow-up interests to be much more homogeneous across sex and race when compared with baseline interests. This directly reflects decreases in several GOTs and BISs among black women. In some select cases, declines were also observed among black men on the BIS. Therefore, the initial trends for fewer interests among white men and white women observed during inpatient rehabilitation had narrowed by follow-up when compared with that of black men and women. In terms of interest change, it is clear that changes were unevenly distributed as a function of sex and race. White women, who reported the most depressed profiles at baseline, 11 reported the largest increase in each of the GOTs. Some changes were also noted among white men and black men. However, the interests of black women had clearly declined by follow-up. The stability coefficients also speak to the relative stability of interests, irrespective of mean level. Black men appeared to have the least stable interests between the times of measurement. Although black women showed the greatest average Scale Table 3: Stability Coefficients as a Function of Age, Race, and Sex White Men (n 169) White Women (n 66) Black Men (n 55) Black Women (n 14) Overall (N 304) Average GOT Average BIS Average special scales Realistic 0.52* 0.67* 0.42* * Agriculture 0.69* * * Nature 0.58* 0.69* * Military 0.51* 0.48* * Athletic 0.72* 0.68* * Mechanical activities 0.54* 0.67* * Investigative 0.58* 0.54* * Science 0.61* 0.64* * Mathematics 0.57* 0.55* 0.44* * Medical Science 0.42* 0.65* * Artistic 0.63* 0.44* * Music/Drama 0.69* 0.43* * Art 0.67* 0.59* 0.49* * Applied arts 0.56* 0.55* * Writing 0.70* 0.54* * Culinary arts 0.51* 0.52* * Social 0.51* 0.69* * Teaching 0.52* 0.62* * Social services 0.49* 0.64* * Medical service 0.32* 0.45* * Religious activities 0.63* 0.68* * Enterprising 0.48* 0.50* * Public Speaking 0.61* 0.53* 0.44* * Law/Politics 0.64* 0.52* 0.55* * Merchandising 0.49* 0.42* * Sales 0.51* 0.49* * Organizing/management 0.55* 0.60* * Conventional 0.50* 0.79* * Data management 0.57* 0.76* 0.42* * Computer activities 0.59* 0.60* * Office services 0.44* 0.82* * Work style 0.63* 0.70* 0.50* * Learning environment 0.76* 0.70* * Leadership style 0.67* 0.64* 0.47* * Risk taking/adventure 0.57* 0.72* 0.62* * *P.001; P.01; P.05.

8 VOCATIONAL INTERESTS AFTER SPINAL CORD INJURY, Krause 595 decline in mean interests, their interests appeared to be more stable in terms of the stability coefficients, which reflect the relative rank ordering of participants on any particular scale. Interpretations Several alternative and sometimes competing explanations exist. First, it may simply be that the interests of blacks, particularly black women, change more in response to SCI. There could be social processes that differentially reinforce change as a function of race. Similarly, the findings may reflect a process in response to the SCI whereby interests become more homogeneous. This would be consistent with interpretations placing a great importance on the dramatic changes brought about by SCI and assume they have a greater influence on interest than demographic factors, including sex and race. To become more congruent, due to the limitations of SCI, changes in interest would be viewed as an adjustment process. Alternatively, one could argue that there were sex and race differences in response to SCI, such that white and black participants responded differently to the baseline assessment itself. If this were the case, it may be that white participants were more likely to report their actual interests, irrespective of SCI, whereas black participants may have responded to what they thought their interests might become after SCI. This could account for the lower stability coefficients among black men and substantially changing mean scores for black women. Similarly, it may be that vocational interests were less developed among black participants at baseline. However, the pattern of differential interests as a function of race observed during baseline was highly consistent with that observed in the general population, where black participants reported higher scores on the Social, Enterprising, and Conventional themes. 12 Therefore, this latter interpretation seems speculative. Clinical Implications These findings present challenges for rehabilitation professionals. First, assessment of interests during inpatient rehabilitation cannot be made without consideration of potential change. Second, the profiles of black men appeared to be relatively unstable based on the stability coefficients. Therefore, even though the mean level of some scales may increase for the group, the profiles for any given individual may change dramatically. Third, differences between white and black women may be particularly prominent. White women may report an initially flat profile, with little change in pattern over time, yet some increases in particular types of interests. In contrast, black women may report diminished interest over time. The finding that interests are changing provides the rehabilitation professional an opportunity to work with the client to find interests congruent with SCI. The number of black women participants was relatively small, so additional research will be required to identify implications for counseling strategies. Nevertheless, 1 clear implication is that we need to closely evaluate vocational interests from the participant s perspective to develop a frame of reference from which to interpret scores. Although this seems particularly important for black women, given the amount of interest change, it applies to all those with SCI. We need to make sure all persons are basing their responses on what they would like to do and are interested in doing, rather than simply what they feel they can do. Study Limitations Given the limited number of black women (n 14), we had 4 basic options for analyses: (1) collapse race and sex to form 4 categories while including a race by time interaction, (2) use a complete factorial design treating race and sex independently with interaction terms, (3) include only race within the design, collapsing across sex, and (4) exclude black women from the analysis. We chose option 1 to balance the scientific integrity of the study with the need for inclusion of the underserved populations. A completely cross-factorial design with 3-way interactions (option 2) would be too unstable, resulting in highly unstable interaction effects. Including only race as a cohort variable, collapsing across sex, would have produced misleading results that would make it appear as though interest declined as a function of race when in reality, this occurs only for black women. Lastly, simply eliminating black women from the study would be counter to the intent of the study of addressing the interests of underserved populations. Clearly, the interests of black women are an important component of the cross-sectional analysis of race and sex differences during inpatient rehabilitation, 11 so eliminating this group from the follow-up would miss several important findings. Furthermore, this would, to some degree, mask the most important trend in the study, which was the tendency for the substantial heterogeneity of interests between groups observed during inpatient rehabilitation to converge by follow-up. There are other limitations. First, our only underrepresented population is black, non-hispanic. There is no reason to believe the results would generalize to other groups. Second, because of sample size considerations, we collapsed follow-up data so as to maximize the number of participants. Therefore, we are unable to observe trends across more than 2 points in time and still report sex and race trends. Third, a new form of the SII has been developed since this study was initiated. This does not change any of the fundamental observations from the study but does limit the normative value of the data. Future Research Additional longitudinal research is needed identifying interest change over a longer period of time. Second, research is needed on underrepresented populations more broadly defined than in the current study. It may be particularly important to identify the interests of people of Hispanic origin. Third, we need to learn more about the relationship between vocational interests and interest change with tangible outcomes. Lastly, although it is important to link vocational interests to employment outcomes, longer intervals will be required to reliably identify these relationships. Because the SII was developed for vocational issues, identifying its relationship with employment outcomes may be particularly important. This will be a particularly important focus of future research. Because the majority of those who work after SCI within the first 2 years return to their preinjury employer, 15 future research of interest and employment must be conducted over longer intervals. According to the same study, it takes nearly 10 years before 90% of those who will work after SCI have done so. Therefore, future studies will require a lengthy follow-up. CONCLUSIONS Interest change after SCI differs as a function of sex and race. The interests of white women are the most stable in terms of pattern, yet also are the most likely to show mean differences increases in select scales. The interest profiles of black men are the least stable over time, whereas black women are most likely to report significant declines in mean scale scores. With the exception of black women, mean scores tend to increase over time on select scales.

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