TRAUMATIC SPINAL CORD injury is typically not a

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1 626 ORIGINAL ARTICLE Vocational Interests After Recent Spinal Cord Injury: Comparisons Related to Sex and Race James S. Krause, PhD, Lee L. Saunders, PhD, David Staten, PhD, Daniel E. Rohe, PhD, LP ABSTRACT. Krause JS, Saunders LL, Staten D, Rohe DE. Vocational interests after recent spinal cord injury: comparisons related to sex and race. Arch Phys Med Rehabil 2011;92: Objective: To compare vocational interests as a function of sex and race among persons with recent spinal cord injury (SCI), because previous research used almost exclusively white men. Limited research from nearly 2 decades ago suggested SCI selectively occurs to men whose vocational interests are consistent with the Realistic theme of the Holland typology, indicative of a preference for activities and occupations requiring physical strength and dexterity. Design: The Strong Interest Inventory (SII) was completed an average of 50 days after SCI onset. Setting: Data were collected at a specialty hospital and analyzed at a medical university. Participants: Adults with traumatic SCI (N 500) were assessed during inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measure: The SII, a 317-item measure of vocational interests. Results: Although the findings for white men were consistent with elevation of the Realistic theme when compared with the reference group, the interests of women and black participants were substantially different. Women scored highest on Social, Enterprising, and Conventional themes compared with the reference group. Black participants reported significantly higher elevations than whites on 5 themes (all except Realistic), with elevations on the Social, Enterprising, and Conventional themes exceeding standardized norms. The Artistic and Investigative themes were least descriptive of the overall sample. Conclusions: Rehabilitation professionals should be aware of likely differences in patterns of vocational interests as a function of race and sex, and use vocational interests as a means of facilitating postinjury adaptation. Key Words: Employment; Occupations; Personality; Rehabilitation; Spinal cord injuries by the American Congress of Rehabilitation Medicine rom the College of Health Professions, Medical University of South Carolina, Charleston (Krause, Saunders); Rehabilitation Counseling Program, South Carolina State University, Orangeburg (Staten), SC; Spinal Cord Injury Rehabilitation Program, Mayo Clinic, Rochester, MN (Rohe). The contents of this publication were developed under grants from the Department of Education, NIDRR grant numbers H133N and H133G However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the ederal 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, College of Health Professions, Medical University of South Carolina, 77 President St, Ste 117, MSC 700, Charleston, SC 29425, krause@musc.edu. Reprints not available from the author /11/ $36.00/0 doi: /j.apmr TRAUMATIC SPINAL CORD injury is typically not a random event, as it occurs disproportionately to those engaging in high risk behaviors. The majority of SCIs are the result of motor vehicle crashes (42.1%), followed by falls (26.7%), violence (15.1%), and athletic events (7.6%). 1 Alcohol intoxication is associated with a substantial proportion of injuries. 2,3 However, etiology varies by sex, race/ethnicity, and age, with acts of violence more prominent among minorities, and falls more prominent among the elderly. As early as 1964, ordyce 4 demonstrated a relationship between imprudent behavior leading to the onset of SCI and similar behaviors observed after SCI onset, suggesting common personality patterns among those with SCI. Rohe and Athelstan 5 obtained Strong Campbell Interest Inventories from 156 participants with SCI an average of 82 days after injury onset (the majority of who were men; n 134), in order to identify common vocational interests and personality types. This measure incorporates Holland s theory of vocational choice that postulates there are 6 personality types, and corresponding environments and people will seek out environments consistent with their personality type. The 6 types include: 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 (business-oriented, persuasive, value social status), and Conventional (orderly, value technical proficiency). Men scored highest on the Realistic theme, suggesting a preference for working with objects rather than with people or data. They scored low on scales related to Social and Investigative interests and were more socially introverted and less academically oriented than the test s normative sample. There were few women in the study (n 22) and race was not reported. Rohe and Athelstan 6 subsequently collected data on a community sample of 117 men. They again found the highest scores to be on the Realistic theme, even though the participants averaged 9.43 years postinjury. Rohe and Krause 7 found interests were highly stable over an 11-year follow-up (n 79). Stability coefficients matched or exceeded those of the general population. This supports Holland s theory suggesting people continue to seek out environments consistent with their vocational interests, even when the interests are incongruent with their physical limitations. In the general population, interests differ by race. Using the 1994 SII, Kaufman et al 8 found blacks scored higher on the Social, Enterprising, and Conventional themes, while whites scored higher on the Realistic and Investigative themes. On the Basic Interest Scales, whites scored higher on Nature, Agriculture, Adventure, Science, Medical Science, and Mechanical; MANOVA SCI SII List of Abbreviations multivariate analysis of variance spinal cord injury Strong Interest Inventory

2 VOCATIONAL INTERESTS ATER SPINAL CORD INJURY, Krause 627 blacks scored higher on Religious, Sales, Public Speaking, Social Service, Law/Politics, Business Management, and Office Practices. ouad et al, 9 utilizing a sample size of 38,000 with 2200 participants who identified as persons of color, concluded that structure of interests were similar across black, Asian, Hispanic, and white professionals. There has been an ongoing debate regarding the generalizability of the SII for those from diverse ethnic backgrounds. Rounds and Tracey 10 conducted a meta-analysis concluding the model did not fit ethnic samples very well. Although the factor structure of the SII appears stable across race, patterns of interest may differ and the fit of Holland s model may not generalize well across ethnicities. Summary and Purpose Despite the importance of the early studies, there are significant gaps in the literature, particularly related to women and nonwhites. urthermore, there has been a changing pattern of etiology and demographics of SCI since the conduct of the preliminary studies. The general literature on race and vocational interests raises questions as to the generalizability of the findings. Because etiologies of SCI vary as a function of race, there are reasons to hypothesize a different pattern of interest may be revealed for nonwhites. The absence of women raises similar questions about generalizability. Our purpose was to identify patterns of vocational interests among newly-injured participants with SCI using the SII and to compare interest patterns as a function of sex and race (white, black). METHODS Participants After obtaining institutional review board approval, participants were recruited during inpatient hospitalization at a large specialty hospital in the Southeastern United States. Data collection began in January 2002 and concluded in September The 6 eligibility criteria were: (1) traumatic SCI, (2) currently hospitalized, (3) at least 16 years of age at assessment, (4) race/ethnicity of white or black, non-hispanic origin, (5) some residual deficits, and (6) assessed within first 6 months after onset. A total of 500 participants meeting these criteria completed materials. Participants averaged 50 days postinjury onset at assessment (median 44.0; range, 2 154). Procedures The SCI peer support coordinator approached new patients to request participation and to obtain informed consent. or those agreeing to participate, a staff member met with the participant and either helped to complete the questionnaire or left the questionnaire for those who did not need assistance. Materials could not always be completed prior to discharge. Participants were given $25 remuneration. All data were entered and verified to ensure accuracy. Measures We used the 1994 edition of the SII, orm T ,12 We are reporting scores on 6 General Occupational Themes from the Holland vocational typology and 25 Basic Interest Scales, which are composed of items with homogeneous item content in specific areas. The General Occupational Themes and Basic Interest Scales are standardized with a mean of 50 and an SD of 10. The median 3 to 6 month test-retest stability coefficient from a sample of employed adults on the General Occupational Themes is.89 and is.87 on the Basic Interest Scales. The SII reflects advances in item technology and sampling over previous versions of the inventory. SII scores are based on comparisons with sex-specific normative groups (ie, male General Reference Sample and female General Reference Sample). Therefore, sex-based comparisons of scores between men and women reflect how the sample of men and women differ from each other relative to their normative group. The male General Reference Sample averages 44.6 years of age, is 8.3% nonwhite, and 5% have a disability. The female General Reference Sample averages 40.5 years of age, is 8.5% nonwhite, and 2.9% have a disability. Analysis Descriptive statistics were used to summarize the characteristics of the study sample and scores on the SII. MANOVA was utilized with follow-up tests to identify significant differences as a function of sex and race (whites and blacks). Separate MANOVAs were run for the General Occupational Themes and Basic Interest Scales. RESULTS Participant Characteristics The breakdown by race and sex was as follows: white men (56.8%), white women (16.0%), black men (22.0%), and black women (5.2%). ifty-one percent reported cervical injuries. The average age at injury was 32.9 years old. our percent completed a master s degree or higher at injury, 7.6% a 4-year degree, 11.2% a 2-year degree or vocational training, 53.8% a high school certificate or General Educational Development, and 23.0% had not completed high school. Seventy-five percent were working at the time of injury. Overall Scores on the SII General Occupational Themes. Results of the MANOVA revealed significant main effects for both sex ( 6, , P.001) and race ( 6, , P.001) (table 1), and also for an interaction effect between race and sex ( 6, , P 0.013). Significant sex differences were observed on 5 of the 6 General Occupational Themes (all except Enterprising). Men scored significantly higher on the Realistic and Investigative themes, whereas women scored higher on the Social, Artistic, and Conventional themes. The most prominent difference was on the Realistic theme where men scored well above the male General Reference Sample mean (54.6) and women scored nearly three quarters of a SD below the female General Reference Sample mean (41.8). In contrast, the differences on the Investigative theme were relatively small, with both men and women scoring well below the male General Reference Sample and female General Reference Sample (men 43.0; women 40.5). The scores for women were at or just above the mean of the female General Reference Sample for the Social and Conventional themes (51.1 and 50.7, respectively); the scores for men were below the male General Reference Sample (45.4 on both scales). Therefore, the significant differences between men and women primarily reflect the absence of typical levels of interests among the SCI men on these scales. The scores of both men and women on the Artistic theme were lower than the normative groups, but the difference for women was smaller (45.5, 39.2). Race differences were observed on 5 General Occupational Themes (all except Realistic), with blacks scoring higher on each of the other 5 General Occupational Themes. Whites scored below the normative sample on all scales. Black participants scored higher than the male General Reference Sample on 3 of 5 themes for which there were significant differences,

3 628 VOCATIONAL INTERESTS ATER SPINAL CORD INJURY, Krause Table 1: Scores on the General Occupational Themes as a unction of Sex and Race ull Sample Men Women White Black Mean SD Mean SD Mean SD Mean SD Mean SD Theme N 500 n 394 n 110 n 364 n 136 Sex Race Sex Race Realistic Investigative * 5.6* 2.3 Artistic Social Enterprising Conventional Abbreviations:, value from the MANOVA test; Sex Race, interaction term between sex and race. *P.05. P.01. P.001. including the Conventional (52.5), Enterprising (52.5), and Social (51.4) themes. On the Investigative and Artistic themes, both blacks and whites scored substantially lower than the normative group (Investigative: black 44.4, white 41.8; Artistic: black 42.9, white 39.6). Basic Interest Scales. Results of the MANOVA revealed significant main effects for both sex ( 6, , P.001) and race ( 6, , P.001) (table 2), and also an interaction effect for race and sex ( 6, , P 0.042). There were significant sex differences on 17 of 25 Basic Interest Scales. Men reported higher scores on 7 of the Basic Interest Scales, including each of the 5 scales within the Realistic theme, and 2 of the 3 from the Investigative theme (Science, Mathematics). Differences on 3 scales were 5 or more points (Agriculture, Table 2: Scores on the Basic Interest Scales a unction of Sex and Race ull Sample Men Women White Black Mean SD Mean SD Mean SD Mean SD Mean SD Scale N 499 n 393 n 106 n 363 n 136 Sex Race Sex Race Realistic Agriculture Nature Military Athletic Mechanical activities Investigative Science * 1.8 Mathematics * Medical science * 1.6 Artistic Music/drama * 2.6 Art * 3.9* Applied arts Writing * 0.0 Culinary arts Social Teaching Social services Medical service Religious activities * Enterprising Public speaking Law/politics Merchandising * Sales * Organizing/management Conventional Data management Computer activities Office services Abbreviations:, value from the MANOVA test; Sex x Race, the interaction term between sex and race. *P.05. P.01. P.001.

4 VOCATIONAL INTERESTS ATER SPINAL CORD INJURY, Krause 629 Table 3: Scores on the General Occupational Themes and Basic Interest Scales as a unction of the Combination of Sex and Race White Men Black Men White Women Black Women Mean SD Mean SD Mean SD Mean SD n 283 n 110 n 80 n 26 Theme/Scale RESCIA RECSIA SCEARI CESAIR Realistic Agriculture Nature Military Athletics Mechanical activities Investigative Science Mathematics Medical science Artistic Music/drama Art Applied arts Writing Culinary arts Social Teaching Social services Medical service Religious activities Enterprising Public speaking Law/politics Merchandising Sales Organizing/management Conventional Data management Computer activities Office services NOTE. General occupational themes are indicated in bold. Abbreviations: CESAIR, Conventional, Enterprising, Social, Artistic, Investigative, Realistic; RECSIA, Realistic, Enterprising, Conventional, Social, Investigative, Artistic; SCEARI, Social, Conventional, Enterprising, Artistic, Realistic, Investigative. Athletics, and Mechanical Activities). Women scored higher on each of the 4 Basic Interest Scales in the Social theme, 4 of the 5 scales within the Artistic theme (all except Applied Arts), the Merchandising scale (Enterprising), and the Office Services scale (Conventional). Of these, 6 were 5-point differences (Social Services, Medical Services, Art, Writing, Culinary Arts, and Office Services). There were race differences on 19 of the 25 Basic Interest Scales (blacks scored higher on 17 scales). Whites scored 5 points or higher on 2 scales within the Realistic theme (Agriculture and Nature). Blacks scored higher on the Athletic scale (Realistic), Music/Drama, Art (Artistic), and all of the scales within the Social, Investigative, Enterprising, and Conventional themes. Eight of these differences exceeded 5 points, including: Social Services, Medical Services, Religious Activities, Merchandising, Organizing/Management, Data Management, Computer Activities, and Office Services. Interactions were observed on 2 scales: Sales and Art (table 3). On Sales, white men scored higher than white women (men 52.6, women 50.0), yet black men scored lower than black women (men 56.0, women 59.3). or Art, while black women scored only slightly higher than black men (men 43.4, women 45.4), white women scored substantially higher than white men (men 40.2, women 47.2). Interest Patterns as a unction of Sex and Race igure 1 summarizes the pattern of interests on the General Occupational Themes for white men, black men, white women, and black women. or white men, the profile is highly differ- ig 1. Pattern of interests on the General Occupational Themes for white men, black men, white women, and black women.

5 630 VOCATIONAL INTERESTS ATER SPINAL CORD INJURY, Krause entiated with the only General Occupational Theme above 50 being the Realistic theme (55.2), with no other theme approaching 50. The pattern for black men is similar, as the Realistic theme is highest (52.8), followed by the Enterprising theme (51.6). However, there is less differentiation, with 4 scales averaging above 50. There are some important differences between white and black women. or white women, there are no scales with a mean of 50 or higher (Social 49.3; Conventional 48.1; Enterprising 47.5). There is a similar, but not identical, pattern of high scorers for black women, although the scale elevations were substantially higher. The Conventional theme was highest (58.9) followed by the Enterprising (56.3) and Social themes (56.2). The Realistic and Investigative themes were the lowest scores for both white and black women (Investigative was lowest for white women; Realistic was lowest for black women). DISCUSSION This study adds to the literature by identifying vocational interests of a sample of 500 participants assessed an average of 50 days after SCI onset, including comparisons of interest as a function of sex and race. Unlike the preliminary research that indicated 1 predominant interest pattern, the current findings present a much more complicated picture that varies significantly according to sex and race. The results demonstrate the folly of generalizing from convenience samples, which frequently consist of white men, to all people with SCI. Our findings are generally consistent with the literature from the general population, 8 in that black participants scored higher on the Social, Enterprising, and Conventional themes; however, no differences were observed on the Realistic theme on which Kaufman et al 8 found whites to be higher in the general population. Significant differences favoring blacks on the Investigative and Artistic themes were not anticipated based on research of the general population. Differences on the Basic Interest Scales also showed consistencies with the general population in that whites scored higher on Nature and Agriculture scales and blacks scored higher on the majority of the remaining scales. However, the race differences among SCI participants exceeded those typically observed in the general population. These findings underscore the importance of not stereotyping a person s vocational potential and interest based on race. There are several important considerations when interpreting the results of the study. Our statistical comparisons evaluate the extent to which the SCI participants differed from the male General Reference Sample and the female General Reference Sample. Consistent with the Holland typology and previous research, men scored highest in the Realistic theme indicative of interests that will be difficult to perform after SCI, particularly for those with severe injuries. This is particularly true for white men. or black men, the average profile was less differentiated with higher overall scores. Therefore, vocational interests cannot account for the highly discrepant employment rates between white and black men reported in the literature, and the diversity of vocational interests among black men may be considered a strength for future employment. Women reported significantly higher scores than men on 3 of the 5 General Occupational Themes for which there were significant differences (Social, Enterprising, Conventional), and these themes are less closely tied to physical strength and dexterity. However, because the interests of white women were depressed (all scale means 50), the interest profiles did not suggest an easy fit for identifying interests that could be used to promote employment. ewer conclusions can be made for black women because of the small sample size, but the overall picture is encouraging, as the average interest profile is differentiated and there are 3 prominent peaks or interests in the Conventional, Enterprising, and Social themes. The overall interest pattern is congruent with the limitations of SCI. In terms of vocational counseling and vocational potential, the overall scores of blacks were similar to the normative groups (average 49.1 across the 6 themes), whereas the scores for whites were, on average, more than half an SD from the normative groups (average 44.9 across the 6 themes). These findings have important clinical implications as they will help vocational counselors and other rehabilitation professionals to understand the most common interest patterns among those with SCI. They also establish race and sex differences in interests among those newly injured with SCI. This helps rehabilitation professionals to understand the diversity of interests between groups with particular characteristics. The specific findings related to race differences in interests establish a foundation for cross-cultural vocational counseling in the extent to which any particular interest pattern may be different from that typically observed for the population. Study Limitations There are several strengths of this study. irst, all data were collected within a short interval after SCI onset; therefore, there was minimal time for interest change prior to assessment. This suggests that the assessment should be an accurate reflection of preinjury interests, although interests may still change over time after SCI (this is a different research question). Second, the sample size was substantially larger than used in previous studies of vocational interests after SCI. Third, whereas previous research was almost exclusively conducted with white men, this study used a more diverse sample. There are also significant limitations. irst, we had a relatively small number of black women (n 26). Second, our only underrepresented population was black. We included other groups within the assessment, but the small numbers precluded independent analyses, and there was no clear rationale for including them with either white or black groupings. Therefore, the study results cannot be generalized to other underrepresented populations such as Hispanics, Asians, or American Indians. Third, since initiating data collection, a new form of the SII was developed. This does not limit our ability to interpret our findings in terms of fundamental differences in vocational interests related to SCI or as a function of sex or race, but it does limit the normative value of the data for comparisons in service delivery settings. Lastly, our data were collected between 2002 and 2006, and since that time, there has been an economic shift that has reshaped the workforce. Given the large and long-standing body of literature that indicates vocational interests are highly stable among adults, 16,17 it is unlikely that the economic shift would change vocational interests, although it may affect the ability of those with particular interest patterns to find employment consistent with those interests. uture Research There are several immediate needs for further research. irst, longitudinal research is needed identifying interest change from the time period shortly after injury through the first few years postinjury. The only existing longitudinal research 6,7 started with a sample that averaged over 9 years postinjury at first testing, and clearly interests could have changed dramatically over the 11-year follow-up interval (even though the profiles were consistent with those generally observed shortly after injury). Second, research is needed on underrepresented

6 VOCATIONAL INTERESTS ATER SPINAL CORD INJURY, Krause 631 populations more broadly defined than in the current study. It may be particularly important to identify the interests of people of Hispanic origin, as language issues may factor into the results. Third, we need to identify the association of vocational interests with critical outcomes, particularly return to gainful employment. Each of these types of studies will further our knowledge of interests and SCI and assist vocational counselors and psychologists in their efforts to promote better outcomes among people with SCI. CONCLUSIONS Interest patterns after SCI differ as a function of sex and race. Whereas our results were consistent with previous research on white men indicating a predominant interest pattern in the Realistic theme reflective of interests in working with things rather than data or people, interest patterns of women and blacks were considerably different. The interest profiles of white women were depressed compared with those of the population norms. In contrast, the interests of black men and women were more consistent with those of the general population and represented a strength in terms of the fit of vocational interests within the limitations imposed by SCI. References 1. National Spinal Cord Injury Statistical Center, Birmingham, Alabama. Spinal Cord Injury acts and igures at a Glance. Available at: Accessed July 14, Alston RJ. Sensation seeking as a psychological trait of drug abuse among persons with spinal cord injury. Rehabil Couns Bull 1994;389: Hawkins DA, Heinemann A. Substance abuse and medical complications following spinal cord injury. Rehabil Psychol 1998;43: ordyce WE. Personality characteristics in men with spinal cord injury as related to manner of onset of disability. Arch Phys Med Rehabil 1964;45: Rohe DE, Athelstan GT. Vocational interests of persons with spinal cord injury. J Couns Psychol 1982;29: Rohe DE, Athelstan GT. Change in vocational interests after spinal cord injury. Rehabil Psychol 1985;30: Rohe DE, Krause JS. Stability of interests after severe physical disability: an 11-year longitudinal study. J Vocat Behav 1998;52: Kaufman AS, ord-richards JM, McLean JE. Black-white differences on the Strong Interest Inventory General Occupational Themes and Basic Interest Scales at ages 16 to 65. J Clin Psychol 1998;54: ouad NA, Harmon LW, Borgen H. Structure of interests in employed male and female members of U.S. racial-ethnic minority and. J Couns Psychol 1997;44: Rounds J, Tracey TJ. Cross-cultural structural equivalence of RIASEC models and measures. J Couns Psychol 1996;43: Harmon LW, Hansen JC, Borgen H, Hammer AL. Strong Interest Inventory: applications and technical guide. Stanford: Stanford Univ Pr; Campbell DP. Handbook for the stong vocational interest blank. Stanford: Stanford Univ Pr; Krause JS, Kewman D, DeVivo MJ, et al. Employment after spinal cord injury: an analysis of cases from the Model Spinal Cord Injury Systems. Arch Phys Med Rehabil 1999;80: Krause JS, Terza JV, Saunders LL, Dismuke CE. Delayed entry into employment after spinal cord injury: factors related to time to first job. Spinal Cord 2010;48: Young AE, Murphy GC. Employment status after spinal cord injury ( ): a review with implications for interpretation, evaluation, further research, and clinical practice. Int J Rehabil Res 2009;32: Rottinghaus PJ, Coon KL, Gaffey AR, Zytowski DG. Thirty-year stability and predictive validity of vocational interests. J Career Assessment 2007;15: Swanson JL, Hansen JC. Stability of vocational interests over 4-year, 8-year, and 12-year intervals. J Vocat Behav 1988;33: