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Edward Steinfeld,Arch D., Professor of Architecture

Scott M. Shea, M. Arch, Research Associate

Rehabilitation Research Center on Aging, State University of New York at Buffalo

Abstract

Environmental barriers can significantly reduce the independence of older people with disabilities living in a residential setting. Removing these barriers through home modification is one way to increase independence. This study focuses on the effectiveness of technical assistance in helping people to make modifications, and the reasons why modifications are not made. Recommendations for improvements to service delivery are proposed based on the study findings.

Research Goals and Background Issues

Potential barriers to the accessibility, safety, security and usability of home environments for older people with disabilities are well known (see Pynoos, 1987 and Watzke and Kemp, 1992). As older people "age in place", these barriers present serious threats to independence and increase caregiver burden. Many methods for eliminating barriers and creating enabling environments have been proposed. However, the needs of individual households vary significantly and they differ from those of younger people with disabilities. There is a need for information on the types of barriers that "handicap" older disabled people, the specific interventions that should be high priorities and the level of acceptance of interventions among the older population. Such information can be used to identify priorities for policy, innovative design concepts, service programs and design of assistive technology. It can help to prevent disability among the older population and increase autonomy. This paper presents findings from the second phase of a multi-year research study concerned with the identification of barriers to aging in place and consumer acceptance of actions to remove those barriers. A previous publication reported on the first phase of the research (Steinfeld and Shea, 1993). The research reported here focuses primarily on the reasons why participants do not implement recommendations of professionals, particularly those that they themselves agree are a high priority.

In an earlier phase of this study we could not explain the priorities consumers gave to recommendations on the basis of cost alone. By analyzing consumer priorities and from informal interaction, we obtained insight into the decision making process (Steinfeld and Shea, 1993). From a cost-benefit perspective, interventions are valued if their benefit outweighs the cost compared to other alternative methods of coping, such as changing behavior. In a risk assessment model, the perceived risk associated with some barriers may be greater than with others, and may be misplaced. Barriers perceived as having low risk are not viewed as real problems. In a cognitive dissonance model, some problems are perceived to be unsolvable and, thus, expectations for resolution are lowered in order to accept the situation more easily. In a social construction model, accepting the need for an intervention is a "reconstruction" of self image, an acknowledgment to others that one can no longer function effectively without adjusting relationships with the everyday world. Denying the need for intervention, on the other hand, presents a courageous image - "It's tough, but I can handle it." As we began the next phase of our research, we realized that there are differences between establishing priorities and actually committing resources to action, thus we considered two other decision making models.The economic constraint model acknowledges that some individuals simply do not have the ability to pay for an intervention, even if they place a high priority on it. Furthermore, in certain cases, an item might be perceived as too expensive when in fact it is affordable. The stress management model is based on the premise that making a change requires some expenditure of psychic resources and energy; some things are perceived as "too much trouble," despite their obvious value. Because of the effort involved, however slight, a change is unacceptable regardless of the impact it might have on their life in the future.

Methods

The first phase of our work obtained descriptive data about the extent and type of barriers to aging in place found in the homes of a sample of older people with disabilities. A barrier was defined as an environmental feature that reduced functional capacity or put a person at risk. We identified 4 categories of barriers: activities of daily living, safety, security and the structural deficiencies. Barriers were identified using a self report method administered as part of a comprehensive Consumer Survey conducted by the RERC on Aging (Mann et al.,1994) and a free home assessment service completed in homes occupied by people selected from the Consumer Survey sample. Recommendations for interventions through home modifications and other related services were prepared and discussed with each individual in order to identify priorities. The participants were alternately assigned to one of two groups as they were recruited. Group One received only the free home assessment and Group Two received additional technical assistance and referral services to help implement any of the recommended interventions. In the second phase, a follow up interview was conducted by telephone approximately 18 months later to identify which additional recommendations had been implemented. For each recommendation that was not implemented, the individuals were read a list of possible reasons and asked to tell us which statement most closely matched their own reason for not carrying out the recommendation. The reasons were based on the decision making models described above but worded in everyday language. Open ended responses were also solicited if the respondent felt our choices didnot apply. Most of the open ended responses fit easily into one of the existing categories. All the participants in the study were over 62, had a disability and lived in non-institutional community housing in the Buffalo metropolitan area. A wide range of disabilities was represented.

Findings

Table 1 shows the total number of recommendations that were implemented. Barriers counted in Phase One were completed prior to the priorities interview and were considered high priority barriers by default. Phase Two data includes the additional actions that were completed after the priorities interview and prior to the follow up.

The individuals in Group Two implemented almost twice as many recommendations as those in Group One by the end of Phase Two. This would seem to indicate that technical assistance and referral services were helpful for resolving problems. However, roughly the same ratio held for the number of barriers resolved by the end of Phase One, before any additional services were actually provided. This indicates that the people in Group Two were generally more inclined ormore able to change their environments than those in Group One.

Table 1. Frequency of Actions

phase

1

2

Total

group

1

2

total

1

2

total

# barriers

321

426

747

321

426

747

747

# actions

30

54

84

19

33

52

136

%

4.0

7.2

11.2

2.5

4.4

7.0

18.2

# hipribar

101

188

289

101

188

289

289

hipri %

10.4

18.7

29.1

6.6

11.4

18.0

47.1



In addition,the number of recommendations implemented decreased over time. This is contrary to what one would expect if providing technical assistance and referral services are effective as a sole intervention. However, this finding does suggest that assessments on their own have an impact in increasing the rate of modifications. The initial assessment apparently focused participants' attention to problems and encouraged them to act.

Overall, only 18.2% of the barriers identified were resolved.However, of the 747 barriers encountered, 289 were considered a high priority and 47.1% of these were resolved. Thus, older people are willing to devote resources toward improving their home environment if they perceive barriers to be serious but they will not devote resources to low priority problems. What are the reasons for the lack of resolution for over half of the high priority barriers? Answering this question can help us discover ways to increase the rate of problem resolution.

An unanticipated reason for inaction was discovered during the interviews, perceived lack of control over the circumstances. This reflects a model of decision making based on autonomy. The individual wishes to resolve the problem but is unable to do so because others have control. This can be attributed in part to respondents living in rental properties. They were reluctant to approach a landlord or had already had a request refused and were hesitant to press their case. Roughly the same number of homeowners gave autonomy as a reason for not taking action. These people all cited family members who were unresponsive to their requests for assistance. Despite owning the home, they were dependent on others to make improvements. However, these homes had fewer barriers.

Table 2. Frequency of Reasons for Inaction

model

n

%

revised %

economic constraint

25

31.6

31.6

stress management

19

24.1

24.1

cognitive dissonance

11

13.9

social construction

5

6.3

self concept

16

20.3

autonomy

10

12.7

12.7

risk assessment

7

8.9

cost benefit

2

2.5

deferred priority

9

11.4

Total

79

100

100



Table 2 shows the frequency distribution of reasons given for inaction on high priority recommendations. Overall, the barriers that were identified and the proposed solutions were perceived as relevant and important, as indicated by the extremely low number identified as cost-benefit, or "not making enough of a difference." While economic constraint was the most frequent reason given for inaction on a recommendation, 68.4% of the barriers were left unresolved for other reasons. Cost is clearly not the only reason why individuals do not make modifications. Stress management was the next most cited reason reflecting another dimension of resource constraints. The frequency of the other reasons were considerably lower than these two. It is possible that our original categories masked the relative importance of different reasons. Upon reflection, we noticed a close affinity between the risk assessment and cost benefit models of decision making. In both cases, the level of perceived benefit can trigger action. Until that benefit is perceived to be significant, either in terms of value or reduced threat, action will be deferred. Likewise, the cognitive dissonance and social construction models are both concerned with self concept. In the former, individuals do not act because they deny a change in status and in the latter, because they blame their limitations as the cause of the problem. Inaction, in both cases, can be attributed to an unrealistic assessment of self. Thus, we revised the categories to collapse these four models to two, "deferredpriority" and "self concept." Conceived this way economic constraints and stress management are still the top two, but self concept is not far behind.

Conclusions

Over half of the barriers that were identified as high priorities by the participants themselves were not resolved at the end of the study period. While, in one sense, it is encouraging to find out that households that have older people with disabilities will take action to remedy problems, a higher level of resolution would be desirable. What can be done to increase the rate of action? Our findings indicate that technical assistance and referral services alone are not sufficient to help improve the rate of action. A different type of intervention is needed.

The results show that there are three major reasons why the older people in our sample did not take action on a recommendation for a home modification. The first is that the economic cost of implementation was perceived as being outside their means. The second was that the physical and psychic energy required to implement the recommendation was perceived to be beyond their capacity. Third, implementation required a realistic assessment of self, specifically the belief that a change in the environment can make a difference in one's quality of life. Such a reassessment was not acceptable in many cases. Two additional but, still important reasons are that the ability to make the change was out of the control of the respondent and that the barrier was not perceived to be important enough yet to demand action.

Previous demonstration studies on this topic have not only provided assessments but also either offered to make modifications free of charge or provided cash grants (see for example Trickey et. al.). These studies reported higher implementation rates. Our findings confirm that the availability of financial assistance is the most important incentive for insuring action. It is important to note, however, that the previous studies did not compare the rate of implementation prior to and after the service intervention. Our findings indicate that this should be an important methodological component of intervention studies.

The research has several implications for improving the delivery of home modification services to support aging in place. First, more attractive financing mechanisms need to be developed. A funding program that could address all the implications of aging in place together and provide a menu of health care, social service and shelter options would increase flexibility in the use of existing funds and thereby address the diverse needs of households. Second, service providers should reduce the stress of implementing home modifications by providing "one stop shopping" for all related services and maintaining high quality and reliability standards that will promote trust and security. Third, ways to reduce the cost of service delivery are needed. Fourth, case managers and outreach personnel need to address the issue of lack of control with strategies to encourage landlords and families to fulfill their obligations. Fifth, educational programs are needed to improve the awareness of aging in place and the advantages of home modifications for the older consumer. Sixth, there is a need to develop low cost, "hassle free" and age appropriate solutions to the common barriers to aging in place.

References

Mann, W. C. et. al. The Rehabilitation Engineering Center on Aging. Technology and Disability.Butterworth-Heinemann: Stoneham, MA. 1994. pg. 284

Pynoos J, CohenE, David LJ, Bernhardt S. Home Modifications: Improvements that extend independence. In Regnier V, Pynoos J, eds. Housing the Aged. New York: Elsevier Science Publishing Co., Inc., 1987

Steinfeld, E and Shea,S. Enabling Home Environments: Identifying Barriers to Independence.Technology and Disability. Butterworth-Heinemann: Stoneham, MA. Fall1993. p. 69

Trickey, Francine et.al. Home Modifications for the Elderly: which ones do they want? Which ones will they use? WINDOW on Technology. vol. 7, no. 4. pg. 8

Watzke, J.R. and Kemp, B. Safety for Older Adults: The role of technology and the home environment. Topics in Geriatric Rehabilitation. Aspen, 1992

This research was fundedby NIDDR as part of the RERC on Aging at the State University of New York at Buffalo.