A Qualitative Examination of Client Participation in Agency-Initiated Services

Altman, Julie Cooper

Abstract

Decisions of nonvoluntary clients regarding whether to accept or decline agency-initiated social services were examined in this exploratory study. A qualitative research approach was used to collect and analyze data from 20 potential participants in an early-intervention program for high-risk (child abuse) families. Each was queried as to their decision-making rationale when confronted with an offer of services. Five themes across the participant decision-making category emerged: need, fit, efficacy, cost/benefit, and choice. Practice implications are discussed, with an emphasis on the importance of seeking and respecting clients' perspectives in the offer of service delivery.

BEFORE WE AS SOCIAL WORKERS can begin to help clients through social work practice, we must engage them first as partners in the process. Essentially, a client is not a client until he or she agrees to be. This first step, of critical importance in practice, has often been ignored in social work research. The purpose of this study is to contribute some knowledge to the field about this critical client-engagement process.

A characteristic of many current approaches to prevention and treatment in social work is that services are usually offered or initiated by an agency rather than specifically sought out by a potential client. In an effort to engage potential clients in positive change processes, social workers may offer services universally or to preselected high-risk pools of clients. Expectations for this approach are high, but there is much to learn about how clients react to, choose, utilize, and change via these services.

It is imperative that social work professionals understand client participation in agency-initiated services because there is an expansion of the number of services offered this way. In the field of child welfare, because the efficacy of available treatment has been limited, more agency-initiated maltreatment prevention efforts have been developed. Offering voluntary, home-based, early-intervention prevention programs is characteristic of the new models of service delivery to high-risk (for child abuse or neglect) families and their infants (Daro, 1993; McCurdy, 1995; Olds, 1992). Yet little is known about the processes that make these programs work, that is, for whom, when, where, how, or why (Weiss, 1987).

Investigations into the use of agency-initiated services in other fields of service where clients may be nonvoluntary are rare. Evaluations that have been done include investigations of the use or nonuse of health care (Andersen, 1995; Bedics, 1994; Cook, Selig, Wedge, & Gohn-Baube, 1999; Padgett, Patrick, Burns, & Schlesinger, 1994) and early-intervention service use by special-needs infants and their families (Kochanek & Buka, 1995). Factors such as motivation, need, locus of control, level of support, stress, values, beliefs, and expectations have been suggested as correlates of client service use. Evidence pointing to program access, time limits on treatment, client-worker relationships, and client satisfaction as related to service use was also reported.

The use of services by nonvoluntary child welfare clients is a promising new area of research (Drisko, 1998; Littell, 2001; Littell & Tajima, 2000; Staudt, 1999, 2000; Staudt, Scheuler-Whitaker, & Hinterlong, 2001; Unrau, 1997). These studies have contributed information about the conceptualization of client participation and identification of critical factors. All, however, have focused on clients' use of services during or after intensive family preservation programs. None focused on primary or secondary preventive services nor looked intensively at the process from a client's point of view.

Although primarily conceptual, knowledge from social work practitioners and educators over the years has enriched our understanding of the complexities of service utilization. Towle (1954) and Ripple (1964) were among the first to search for a clearer understanding of client service usage patterns. Building on this foundation, Reid and Epstein (1972) constructed an empirically based treatment model, the task-centered approach to social work treatment. Along with its many valuable components, this model proposes that there is a set of obstacles that interferes with a client's ability to solve problems. The six basic obstacles described by Reid and Epstein are when the client lacks concrete resources, reinforcement, skills, or the capacity to perform tasks. Clients may also have adverse beliefs, or the worker may be biased and/or unskilled. An adaptation of this framework proved useful as the conceptual foundation for this study and serves as the guiding framework for the interview guide (see Table 1).

Method

The central research question of this study was as follows: How do potential clients, when confronted with an agency-initiated offer of service, decide whether to accept or decline that offer? Secondary questions focused on the underlying processes and dynamics: What were clients' perceptions, beliefs, attributions, or expectancies regarding themselves, the helping professional, the identified problem, and the offer of service? How did these client factors influence their decision to accept or decline services?

A qualitative approach to studying these questions was used. Ethnoscientific methods (Spradley, 1979, 1980) seek to discover the meanings persons create for themselves, their world, and decisions related to both. In this study, participants were queried to determine what meanings they placed on their decisions to participate (or not) in agency-initiated services.

A large, urban, nonprofit community health center's program for child abuse prevention and early intervention situated in an impoverished neighborhood in a mid-sized northeast U.S. city was chosen as the collaborative research site. Families were referred to this program after assessment showed that they were at high risk for abuse or neglect at the time of a child's birth. Referrals typically came from community health care providers but could also come from other sources, including preventive public child welfare programs. Each referred family was contacted by a social worker at the program for an intake interview. Clients of this program could be described as nonvoluntary, as distinct from involuntary (Rooney, 1992). They had what may be described as an attributed problem, as opposed to an acknowledged problem. Unlike involuntary clients, they were, theoretically, free to accept or decline the offered service. If accepted, services started within 1 month of referral; the average length of service delivery per family was 1 year. These services included at least weekly home visits by trained early childhood professionals to provide support, education, and other early-intervention resources to the child-parent dyad. Physical therapy, occupational therapy, speech services, and social work services were provided as part of a team approach.

A human subjects review was applied for, and approval was granted. Initial recruitment letters were sent, on a rolling basis, to all participants who had been referred to the program within a 12-month period. The letters were sent within 2 months of the referral. A second recruitment letter and a follow-up phone call followed, if needed. In 12 months, 76 referred clients were solicited for research participation; 23 responded that they were interested, with 20 ultimately participating. An analysis of this subgroup yielded no significant differences from the 56 participants who chose not to participate in terms of race, age, number of children, ZIP code, or socioeconomic status. Participants were given a stipend of $20 for the first interview and $25 for the second.

Intensive interviews were conducted with this sample of 20 study participants. The participants were all women. Their average age was 36.4 years; 5 were Caucasian, 12 African American, and 3 Puerto Rican.

To ensure a purposive spread of the range of program participation from this sample, I classified them by a criterion related to the level of service use demonstrated by the time of the first interview (which was typically within 3 months of having been offered services). Acceptors were defined as those clients who gave every indication, both verbally and behaviorally, that they wanted to participate in the services offered and would continue to do so. That is, they opened the door to routinely accepting home visit services. Reluctant acceptors were clients who had verbally agreed to accept the services but went on to indicate a reluctance to participate fully in the program either verbally or behaviorally (e.g., canceling appointments). These reluctant clients, however, did participate in some services during the first few months. Decliners were nonusers of the program. They gave no indication, either verbally or behaviorally, of a present or future likelihood of participation in services. Ambivalent decliners were those who had verbally declined initial participation in the program but then went on to indicate an interest, either verbally or behaviorally, of present or future participation in the program within 3 months of the offer of services. They may have, for example, phoned to ask further questions regarding the program. The sample included 7 acceptors, 7 reluctant acceptors, 3 decliners, and 3 ambivalent decliners.

An interview guide was constructed based on the guiding conceptual framework categories (see Table 1). Participants were asked for their perceptions, attitudes, experiences, and beliefs in each of the five domains of the conceptual framework: the offered program, beliefs about themselves, information about specific worker or service factors, their own skill and functioning, their concrete resources, and the interpersonal support and/or demands they perceived. Data collection consisted of two in-depth interviews with each participant at a site of their choosing. After informed consent was granted, each interview lasted between 1 and 2 hr, and it was tape recorded. Data were then transcribed, and the more formal process of analysis began.

Spradley's (1979) developmental research sequence was used as the primary qualitative analytic process. Broad cultural domains were identified as a first step in a process known as domain analysis. Transcripts were read numerous times in an effort to develop these primary conceptual categories. One domain, for example, included all the reasons (known as included terms) people gave for accepting services.

Taxonomic analysis was clone next so that I could explore each cultural domain more deeply. A taxonomy was constructed to show the relationships among all the included terms in a domain. For example, in the domain "reasons for accepting services" four subcategories emerged. These were "a need seen," "program fits," "believes in formal help," and "support."

Third, sketch maps of each participant were created. Sketch maps were diagrammatic flows of the participant's decision-making process. Themes in the data were identified through the comparing and contrasting of taxonomies and the development, examination, and overlaying of sketch maps.

As a final analytic process, matrices were developed by decision-making category. The matrices attempted to categorize prevalent themes by participant status. This iterative use of domain analyses, taxonomic analyses, and sketch maps in the search for common themes proved useful. The themes were well established and validated via the different analytic processes. Five main themes were uncovered across decision-making categories: need, fit, efficacy, cost/benefit, and choice.

Credibility was established through the building of trust with research participants over the data collection period. Member checks (Lincoln & Guba, 1985) were used during the second interview to ensure that the themes and conclusions discovered from first interviews or other participants' interviews were adequate representations of their realities. In keeping with the high standards of trained clinical social workers, careful attention was paid to building relationships with the research participants and using skilled interviewing techniques. An auditor familiar with the study checked dependability and confirmability through the triangular cross-checking of my reflexive journal and the analytic records, such as raw data, notes, domain worksheets, taxonomies, matrices, and memos.

Results of Data Interpretation

The five themes found in the data are best conceptualized by questions participants posed in their decision-making process:

1. Do I have a need for services? (Need)

2. Do I think the program will fit with what I may need? (Fit)

3. How effective might the program be for me? (Efficacy)

4. What are the downsides or potential costs as well as potential rewards or benefits of accepting or declining services? (Cost/Benefit)

5. What are my other options? Do I have some choice in this decision? (Choice)

These major themes were found across decision-making categories, and no pattern by category was discovered. The themes also follow no particular linear or hierarchical order. A description of how each theme was articulated both within and across decision-making categories now follows.

Need

An early and primary theme that developed during data analysis was to assess whether participants felt they needed the offered service. Some denied the need for service, either for their children or for themselves, whereas others seemed to minimize the need for the services. Acceptor participants were the only ones to clearly acknowledge that either they or their child(ren) had legitimate needs for the service offered. All other participants questioned the need for the services.

Here, a participant clearly disagreed with the assessment of professionals on the extent of her need for the offered service:

It's not that I didn't believe ... I, I personally didn't feel she needed anything ... and, um ... even when the doctor said that, her muscles are tight, I kind of brushed it off, I didn't think anything was wrong with her ... and I still don't think anything's wrong with her.

This parent did not agree with the significance of the needs identified by professionals:

I was on the defense a little bit because she's my daughter, because they sent back a report saying her motor skills were a little behind, and that ... I didn't think ah ... like I said, she's just a baby, some kids learn before others, you know.

This service acceptor articulated her legitimate need for the services: "I knew what they were saying was true ... so, umm ... I was glad for 'em to help, to try to help ..."

Fit

A second major theme culled from the data involved the kind of fit participants felt that the program might have for them, should they choose to participate. This consideration seemed quite independent from need. Participants who did not feel that they or their children had a need for die program sometimes felt that the program fit in their lives anyway.

A major dimension of fit was defined by participants as their preconceived expectations of the program and the reality as it was presented to them at the time of referral or intake contact. Did the reality of what they were being told about the program fit with what they expected of the services? Acceptors typically felt that the program, as described at the time it was offered, was what they had anticipated.

Interviewer: Alright ... tell me a little bit about what you expected the Birth to Three Program to be like.

Participant: Pretty much what they're doin', umm ... you know, tell me where be is and where he should be, and ... umm ... when he's 3 years old, he'll either be pretty much caught up, or ... So pretty much what they're doin'.

Occasionally, participants seemed to accept or decline services on the basis of the fit of some specific program component, for example, the site of service delivery or the focus of the intervention. Still, others seemed to accept or decline on the basis of some very pragmatic rationale regarding fit, for example, the timing of the intervention. This parent, a decliner, expressed a feeling of being overserviced at the time:

The hospital told me about it, at discharge. I didn't call because at the time I was having the visiting nurse, plus lots of medical appointments, my methadone program visits, and I had to take care of [my child], so I couldn't spare the time it would've taken.

Efficacy

The third theme about decision making was the participants' assessments of the efficacy of the program, independent of whether they felt the need for the program's services or whether the fit was exact. This theme was portrayed in two ways: the perceived efficacy of the intervention itself and the perceived efficacy of the worker who made initial contact. This ambivalent decliner reflected on the theme of efficacy: "Now me, I'd jump at it [any service offered].... It's no problem as long as they're helpin' a child.... And me, ... like if I'd known it would help him, I'd be happy." This acceptor saw the ease and effectiveness with which the worker interacted with her child:

"I trust her a lot ... working with [my child].... She works real good with her, and each time she come back she bring something different, you know, to play with her with.... She good with her ... she real good with her."

Cost/Benefit

The fourth theme was perceived cost/benefit. Participants' comments could be classified in four subcategories: (a) the costs in trying were so low that any benefit would be worth it, (b) the costs of being involved in formal help might be high but so might the benefits, (c) the cost of doing nothing might be unacceptable, and (d) all that really mattered were the benefits. Some respondents expressed a more equivocal view of the cost/benefit analysis. They believed that, at the very least, intervention "could do no harm," even if it did not result in much benefit. Many participants focused on the costs associated with opening their lives up to formal help or the costs of retribution (especially from child welfare) they might experience for declining services. A number also discussed the present and future costs of doing nothing.

This participant, a reluctant acceptor, captured the low cost/potential benefit argument:

For me it was, I'm sure it's not going to do any harm.... Even if I had doubts that she didn't need it, it's not gonna do her any harm, really; it's like giving you a back rub, you know it's not gonna hurt.... It might even feel good, you know ... but if she needed it.

All participants indicated that the decision to participate was not simple or straightforward. Although theoretically they had free choice in the matter, those involved with public child welfare seemed more wary of the consequences of any choice they made and put more weight onto their decision regarding cost/benefit than families not involved in child welfare did. For them, the cost-benefit ratio was more complicated. If they allowed people in their home, it could cost them their privacy. If they did not, it could cost them their relationship with child welfare authorities: "Why a lot of people don't accept it, because, especially state people, because they think they pryin' into your business, and makin' things a lot worse."

Parents considered the costs for their children when they declined the offered service. This mother, who was addicted to drugs, discussed what she saw as the cost associated with her merely doing nothing:

I knew that, you know ... that some of the reasons he was probably in the program was because of me, and I felt that it was me, that I get him somehow involved in some kind of program to help him.... Yeah, that was bad, you know ... because he didn't ask to come here ... you know, and it's my responsibility to take care of my kids.

Choice

Choice was the fifth theme culled from the data. For many, free choice was seen as an illusion. For others, it was perceived and appreciated as a reality. Some evidence of psychological reactance (Brehm & Brehm, 1981) influencing decision making was seen. Clients who felt they had free choice to accept or decline services showed greater likelihood of accepting or declining proffered services in an unambivalent fashion. Clients who felt they did not have free choice were more likely to be seen as ambivalent or reluctant in their decisions.

Locus of control was a complicating factor in choice. Reluctant acceptors and ambivalent decliners were more likely to say that they had a high internal locus of control. Although they were less likely to see their choices as free (and thus exhibit reactance), they were also more contemplative in their decisions to accept or decline. They perhaps felt they had more at stake than those pure acceptors or decliners who more often admitted having a high external locus of control.

Here, a true acceptor describes how freedom of choice played into her decision to accept services:

And my thing is, I chose the program because I wanted to, not because a gun was put to my head, or, you, you did this when you were carrying your child, none of that. ... I did that because I wanted to, nobody forced me-her, the two ladies sitting down on the floor that was here ... none of them.

Parents appreciated feeling they had the choice to accept or decline services:

It was my own decision, and that was just cool ... and I like that she was open up, as though, you know, "Well, [parent's name], I not tryin' to get nothin' on you, this is confidential; it's up to you, I'm not pressin' you to get in," but this is what I want to do, this is me. Social workers have to let them know. "Yes, these are your rights before we walk in your house. If you want us, yes, if you don't want us, you have the right to say no." That's what social workers should tell 'em ... how to stand on your own ... 'cause you're not always going to be with us, are you?

Discussion

It is both important and timely to understand a critical, complex process such as nonvoluntary client service use in the context of a burgeoning growth in agency-initiated services. This study differed distinctly from previous studies in several important ways. First, it focused solely on the earliest critical juncture in the service utilization process when clients decide, presumably on the basis of a number of factors, whether to take part in the process. An important prelude to treatment process and outcome research is to learn more about how clients decide whether to take part in treatment. Second, whereas nearly all of the service utilization literature reviewed focused on client-initiated treatment, this study investigated prevention-focused, agency-initiated treatment.

Client decision making regarding agency-initiated help was a complex process, not just a linear sequence of decisions. The independent yet interwoven themes of need, fit, efficacy, cost/benefit, and choice discovered in this study can assist social work practitioners, program planners, and evaluators as they work toward improving the lives of those they serve.

Implications

A primary contribution of this research is the importance of understanding clients' perceptions of themselves, their children, and their needs. Perceptions, expectations, attributions, and beliefs about themselves, their situations, and the offer of help were central to their decisions about service use. The importance of this theme has now been substantiated in related service-use research (Anderson, 1995; Littell, Alexander, & Reynolds, 2001; Rooney, 1999). Specific practice implications of this research follow according to decision-making theme and are outlined in Table 2.

Need

In this study, parents reported that believing in the need for service was important to them as they contemplated the agency's offer. Some were pleased by agency workers' recognition of their need; others saw a clear need themselves; and still others felt services were a right owed to them, regardless of need. Some parents felt unable to meet the needs of their families currently; others worked to normalize the need. Many reported that the need for concrete services was always present, and its fulfillment was much appreciated.

Other parents, those more likely to decline services, denied or minimized the need for services. Those who reported shifting from a denial of need to an acceptance of need cited the development of a relationship with the worker-even in one appointment-as critical.

Practitioners must go beyond paying lip service to the principles of client self-determination and start to work closely with clients to understand how they view their own or their children's needs for service. It is crucial to ask very early in the engagement process about how people view their own situations. It is important for practitioners to more cautiously approach how their assessments of their clients' needs get conveyed. For example, delineating between need and deficit would seem important. Differences between the client's perception of needs in contrast to wants must be teased out with clients. Is a need a need even if the client does not see it as one? How can a mutual problem-solving process begin?

Exploration of the limits of ethical social work intervention is also relevant with respect to the theme of need. Is it ethical and appropriate for clinical social workers to help individuals change their perception of need? Is it a violation of client self-determination or is it merely "lending vision" to the client? Could this be seen as merely a step before helping one to change? How might it be linked to motivation?

Future areas of study include further exploration of the concept of need and the use of services. One particularly ripe area is to explore in greater detail how workers view a prospective client family's need, how they then may tailor the offer of service, and how this leads to effective engagement.

Fit

The theme of fit described by clients was conceptualized in three ways. Some discussed how the proffered services met or did not meet the anticipated expectations that they held prior to intake. It cannot be emphasized enough that what gets communicated about a program among potential client communities is critical. Other clients discussed program-specific fit. They said that things like the program philosophy, the home-based service environment, and the feeling of rapport they experienced with the intake worker were important and helped them reach decisions about the service offer. Third, participants discussed the pragmatic fit of the program with their lives. Some felt the service was redundant; that is, they were being overserviced. Others felt the timing of the service offer was off. Some felt unsafe in having services delivered to them.

Attention should be devoted to clients' perceptions of the fit of the offered service(s) in their lives. Practical considerations often come first, regardless of how much clients feel they need a service or feel it is an effective service. Practitioners know well the frustrations faced when trying to deliver a service that appears not to fit in with the client's own life plan. This lack of fit can be characterized variously as resistance, dropping out, or worse, and the net result is lost worker time, agency cost, and worker pessimism that change will ever occur. Social work program planners need to work toward a better fit between the real needs of clients and agency programs.

Questions about who decides what is a real need and what is the role of professional expertise in respecting client choice and self-determination can be complicating factors. Social workers have an obligation not only to the one who can make a decision (e.g., the parent in child welfare), but also to the one who can't make a decision (e.g., the infant in child welfare).

Rooney (1999) offered a conceptualization of one aspect of these dilemmas. Motivational congruence (Reid & Hanrahan, 1982; Rooney, 1992; Videka-Sherman, 1985) is best described as the relative fit between the practitioner's and the client's view of concerns. Rooney (1999) used this concept as a basis for the development of techniques to help to maintain the integrity of the relationship in the engagement process between worker and client. The hope is that clients and workers can agree on a goal and work toward it. If the services are effective in reaching the goal and the client experiences some success, then some congruence about the extent of their needs may begin as well.

Efficacy

The research data suggest that the clients' perception of the efficacy of service impacts their decision to accept or decline service. Furthermore, perception of the potential efficacy of both the social worker and the specific intervention was deemed important. For instance, participants suggested that the intervention had to be useful to them, that it had to compare favorably with other interventions, and that its outcome would be better than the client could achieve alone. The perception of a worker's efficacy was based on the client's first impressions of their usefulness, their trustworthiness, their support and concern, and how good they were with the baby.

These findings reinforce the importance of evaluating programs, of assuring that best practice occurs, and of practitioners' communicating truthfully about the effectiveness of offered treatment. Engaging clients in the process requires being able to clearly and honestly explain the service offered and its potential benefits and effectiveness.

The theme of efficacy warrants a greater focus on social work evaluation. Evaluators must improve efforts at determining the effectiveness of the services offered. Clearly, practitioners should strive to deliver the most effective services possible. As part of this implied promise to clients, information on program effectiveness needs to get to the front-line practitioners who initially discuss the services with prospective clients.

Cost/Benefit

Participants viewed differently the relative cost/benefit inherent in the decision they chose regarding agency-initiated services. Some focused heavily on the perceived costs associated with accepting or declining the services. These costs included the guilt and blame about the possible repetitive history of neglect associated with doing nothing for their child. They were also concerned about a lack of privacy, a depletion of their energy if they accepted services, and the associated stigma attached to receiving such services. Others described potential rewards such as receiving specific help immediately and working toward a brighter future for their children. Many described both the costs and benefits of their decisions in the context of their relationship with child welfare services. If they declined services, it could anger the authorities; if they accepted, it would mean increased surveillance and the fears that may bring. Still others felt that it did not hurt to try out the services.

In fact, it may be clients' perceptions of the costs associated with accepting or participating in the program service that prevents them from engaging. This theme resembles Reid and Epstein's (1972) early conception of "client having adverse beliefs." It is therefore important for practitioners to take the time to understand clients' perceptions of potential cost and benefit at the time of the service offer. It is also an opportunity to reinforce with clients any potential benefits that the worker sees.

Choice

In this study, participants expressed that choice was an important yet complex issue that arose during their contemplation of service acceptance. Free choice was considered primary by clients as they contemplated what were their best decisions. Clients who perceived that they had significant control over their lives and maintained a high level of accountability in their decisions and outcomes agonized over what to do. Those who perceived that they had little control over their lives agonized less and were more apt to be straight decliners or acceptors.

Given the overrepresentation of families of color within the child welfare system, it is important to consider potential implications from this finding. Families of color often feel coerced, distrustful, or fearful of public social service systems. They are also less likely to report an internal locus of control. Therefore, it is important that workers do their best to reach out to potential clients of color and to be aware that their sense of control over their lives may impact decision-making patterns. Exploring the feelings of fear, distrust, and coercion is called for, as is an exploration of the reality of their freedom to choose.

Program planners should consider these findings as they refine intake and outreach procedures for nonvoluntary clients. As much as practitioners may think clients need and should use the services offered, they must also remember the maxim of client self-determination and the wisdom that demonstrates the worth of that maxim. Even so, many social workers share a bias that the use, not refusal, of agency-initiated services by clients is in their best interest. Participants in this study made clear the importance of their perception of having free choice in the matter of accepting or denying offered services.

Conclusion

The research reported advances the body of knowledge about the use of services by nonvoluntary clients by inductively understanding clients' perceptions of their own decision-making process when offered agency-initiated services. The findings show that when clients contemplate how they will participate in deciding about service delivery, their perceived need and their perception of the fit of the offered service and its perceived effectiveness all matter. Furthermore, it also mattered to clients during the decision-making process how they viewed and weighed the relative costs and benefits of their participation and how they viewed their ability to freely choose whether to accept or decline services.

Although the outcomes of this research cannot fully explain or predict client decision making, they help clarify a little-understood preliminary process in the continuum of client change: that of service acceptance and use. As growth continues in prevention-oriented, agency-initiated formal social service, it is imperative that practitioners gain additional understanding of client participation in those services. These findings on how clients choose to accept or decline agency-initiated services should enrich the ways we proffer, intervene through, and evaluate those services.

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Julie Cooper Altman, PhD, is assistant professor, School of Social Work, Adelphi University, Garden City, NY 77530. Dr. Altman ha also been in practice as a social worker, program supervisor, and consultant.

E-mail: [email protected].

Note. This paper is based on work funded by the Fahs-Beck Fund for Research and Experimentation and also supported by a Dissertation Fellowship Award from the University of Chicago School of Social Service.

Manuscript received: April 1, 2002

Revised: September 24, 2002

Accepted: January 14, 2003

Copyright Families in Society Oct-Dec 2003
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